1. 1. Full name, business and residence addresses, and telephone numbers, residence addresses for the past five years, date of birth, place of birth, social security number if the individual is willing to provide it, and two references; and

2. 2. An authorization for release of personal information, on a form prepared by the commission, signed by the individual providing that he:

   1. a. Authorizes a review by, and full disclosure to the Federal Bureau of Investigation, an agent of the Virginia State Police, of all records concerning the individual;
   2. b. Recognizes the information reviewed or disclosed may be used by the Commonwealth of Virginia and the commission to determine the individual's qualifications for a license; and
   3. c. Releases authorized providers and users of the information from any liability under state or federal data privacy statutes.

In an application for a license, the applicant shall include the following with respect to each individual identified as an applicant, partner, director, officer, other policymaker, or holder of a direct or indirect record or beneficial ownership interest or other voting interest or control of 5.0% or more in the applicant, any lease holder of a site of satellite facility, and each individual identified pursuant to subdivisions 2 and 3 of 11VAC10- 40-220.

Statutory Authority

§ 59.1-369 of the Code of Virginia.

Historical Notes

Derived from VR662-02-05 § 2.18, eff. March 23, 1994.