Quiktrip #491 Redacted Application # 399828.pdf

Received in the Buckeye City Clerk's office June 01, 2026 at 12:05 p.m. by LCA

State of Arizona
Department of Liquor Licenses and Control

Created 05/28/2026 @ 03:06:16 PM
Local Governing Body Report

LICENSE
Number: Type: 010 BEER AND WINE
STORE

Name: QUIKTRIP #491
State: Pending
Issue Date: Expiration Date:
Original Issue Date:
Location: 350 N JACKRABBIT TRAIL

BUCKEYE, AZ 85326

USA
Mailing Address: |

TULSA, OK 74101

USA
Phone:
Alt. Phone:
Email:

AGENT

Name: RYAN WITNER ANDERSON
Gender: Male

PHOENIX, AZ 85004

USA
Alt. Phone: |
Email: es

OWNER

Name: QUIKTRIP CORPORATION
Contact Name: RYAN WITNER ANDERSON
Type: CORPORATION
AZ CC File Number: F08755030 State of Incorporation: OK
Incorporation Date: 05/14/1999
Correspondence Address:

TULSA, OK 74101 Q

— «3 yw
Alt. Phone: \p nN

Email:
Page | of 4 A

Officers / Stockholders

Name: Title: % Interest:
CADIEUX FAMILY HOLDINGS LLC Stockholder 70.78
CHESTER EDOUARD CADIEUX III CEO

QUIKTRIP CORPORATION - Stockholder

Name: CADIEUX FAMILY HOLDINGS LLC

Contact Name: PERRY CHARLES HUELLMANTEL

Type: LIMITED LIABILITY COMPANY

AZ CC File Number: State of Incorporation:

Incorporation Date:

Correspondence Address:
TULSA, OK 74101

USA
Alt. Phone:
Email:
QUIKTRIP CORPORATION - CEO
Name: CHESTER EDOUARD CADIEUX III
Gender: Male

Correspondence Address:
TULSA, OK 74101

USA
Alt. Phone:
Email:

CADIEUX FAMILY HOLDINGS LLC - Managing
Member

Name: CHESTER EDOUARD CADIEUX III
Gender: Male
Correspondence Address:

TEMPE, AZ 85280

USA
Alt. Phone:
Email:

MANAGERS

Name: CHRISTOPHER MICHAEL CARLSON
Gender: Male

——

PHOENIX, AZ 85004

USA
Alt. Phone:
Email: Pe

Page 2 of 4

RREKKAEKKKEKKEKEREKE EEK RRREREEREERREREEEER ERE REE EERREEEEEE

Name: CYNTHIA NAVARRETE SERRANO
Gender: Female

Correspondence Address:
TULSA, OK 74101
USA

Phone: a

Alt. Phone:

Email: es

APPLICATION INFORMATION

Application Number: 399828
Application Type: New Application
Created Date: 05/11/2026

QUESTIONS & ANSWERS

010 Beer and Wine Store

1) Are you applying for an Interim Permit (INP)?
No
2) Provide name, address, and distance of nearest school.
(If less than one (1) mile note footage)
Great Hearts Roosevelt - 555 S Jackrabbit Trail, Buckeye AZ 85326
Approx 4,752 feet
3) Are you one of the following? Please indicate below.
Property Tenant
Subtenant
Property Owner
Property Purchaser
Property Management Company

Property Owner

4) Is there a penalty if lease is not fulfilled?
No

5) Is the Business located within the incorporated limits of the city or town of which it is located?
Yes

6) What is the total money borrowed for the business not including the lease?
Please list each amount owed to lenders/individuals.

$0
7) Are there walk-up or drive-through windows on the premises?

No
8) Does the establishment have a patio?

No
9) Is your licensed premises now closed due to construction, renovation or redesign or rebuild?

Yes
If yes, what is your estimated completion date?
04/2027

Page 3 of 4

DOCUMENTS

DOCUMENT TYPE FILE NAME UPLOADED DATE
MISCELLANEOUS Cover Letter.pdf 05/11/2026
QUESTIONNAIRE Chester Cadieux III PQ & Statement.pdf 05/11/2026
QUESTIONNAIRE Cynthia Serrano PQ & Training 05/11/2026
Certificates.pdf
DIAGRAM/FLOOR PLAN Diagram.pdf 05/11/2026
ALIEN STATUS Ryan W Anderson Alien Status Form.pdi05/1 1/2026
QUESTIONNAIRE Ryan W Anderson PQ.pdf 05/11/2026
ORGANIZATIONAL DOCUMENTS Org Chart.pdf 05/11/2026

Page 4 of 4

GUNES + 44)

MUIR Tp feet

350 N Jackrabbit Trail
Buckeye, AZ 85326
Total SF 5,312

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DATE: DRAWN BY:

QuikTrip Corporation
Organizational Chart

QuikTrip Corporation
(Licensee)

Chester E. Cadieux II] - CEO

Cadieux Family Holdings LLC
(61.22% owner of QuikTrip Corporation)
(70.78 % of Class A Shares)

Chester E. Cadieux II - Managing Member

*No individual owner of Cadieux Family Holdings, LLC
owns 10% or greater interest in the licensee

ce 3 ¢

en) £24, PH 4 Bd
Arizona Department of Liquor Licenses and Control
https://www.azliquor.gov DLLC USE ONLY
Job #:

(602) 542-5141

“ ( Aut

License #

Personal Information
Questionnaire

ATTENTION APPLICANT: This is a legally binding document. An investigation of your background will be
conducted. Incomplete applications will not be accepted. False or misleading answers may result in the denial or
revocation of a license or permit and could result in criminal prosecution.

THE COMPLETED QUESTIONNAIRE NEEDS TO BE SUBMITTED TO THE DEPARTMENT ALONG WITH A $22. FEE, AND FD-258
FINGERPRINT CARD, THAT HAS BEEN SEALED IN AN ENVELOPE, AND SIGNED OR INITIALED BY THE FINGERPRINT TECHNICIAN, MUST
INCLUDE THE FINGERPRINT VERIFICATION FORM. MUST BE COMPLETED BY A RECOGNIZED FINGERPRINT SERVICE OR LAW
ENFORCEMENT AGENCY.

—=>=>==
Agent: a person who
is designated by an
applicant or licensee
to receive
communications from
the department and to
file and sign
documents submitted
to the department on
behalf of the applicant
or licensee. An agent
is not a manager.

A.R.S. §4-202(A).

Controlling Person:
person directly or
indirectly possessing
control of an applicant
or licensee.

A.R.S. §4-101(10).

a
Manager: An

individual (not an
entity) approved by
the Department of
Liquor who has the
authority to organize,
direct, carry out,
control or to
otherwise operate the
day-to-day operations
of a liquor-licensed
business.

A.R.S. §4-101(22) and
A.R.S. §4-202(C)

5/5/2025

- Driver’s License #:
. Are you a resident of Arizona? [¥]Yes [No
. Email address:
Home Address: is

. Daytime phone #: _ Alternative phone #: : £7

. License Number:
. Business Name (doing business as):

. Business Address:

SECTION - 1 INDIVIDUAL INFORMATION

[aGent CICONTROLLING PERSON [MANAGER
. Name:_Anderson Ryan Witner
Last First Middle
. Social Security aC Birth Date:
INOT a public record) (NOT a public record)

AZ

State Issued:

(NOT a public record)

Date of residency: 08 /23 2001

SECTION 2 — LICENSED BUSINESS INFORMATION

QuikTrip #491
350 N Jackrabbit Trail, Buckeye AZ 85326

Page 1 of 2
Individuals requiring ADA accommodations please call (602}542-2999

"tte 3 ous LA.

SECTION 3-DAY TO DAY OPERATION OF BUSINESS .

co

Must attach copies of Basic and Management Title 4 training certificates for person managing the day to day
operation of the licensed business.
Who is managing the day to day operations? Loagent (controlling Person [k]Manager

Name of persons who will be handling the day to day operations:__ Cynthia Serrano

SECTION 4 —- BACKGROUND

If you answer “YES” to any Question 1 through 5 YOU MUST attach a signed statement. Give complete details including
dates, agencies involved and dispositions. CHANGES TO QUESTIONS 1-5 MAY NOT BE ACCEPTED

1. Have you owned, or been a controlling person of any entities that held a liquor Yes [] No
license in Arizona, or any jurisdiction, in the past 5 years?

2. Have you been cited, arrested, indicted, convicted, or required to appear in Yes Ol No
court for violation of ANY criminal law or ordinance, regardless of the
disposition, even if dismissed or expunged, within the past 5 years?

3. Has an entity in which you are or have been a controlling person had an Yes [] No
application or license rejected, denied, revoked, or suspended in or outside of
Arizona within the last 5 years? A.R.S.§4-202(D

4. Have you had ANY administrative law citations, compliance actions, or Yes [J] No
consents, in any jurisdiction in the past 5 years? (Do not include civil traffic
tickets)
A.R.S.§4-202,4-210
“Administrative Law Violations are any civil penalties, fines, suspension,
or revocations of your liquor license.

5. Has anyone EVER obtained a judgement against you the subject of which Yes [] No
involved fraud or misrepresentation?

SIGNATURE
Witner Anderson

hereby swear under penalty of perjury and in

O(A)(2) and (3) that | have read and understand the foregoing and verify that
As that | have made herein are true and correct to the best of my knowledge.

05/11/2026
Date:

$/5/2025 Page 2 of 2
Individuals requiring ADA accommodations please call (602)542-2999

cr

rut
Pa

Arizona Department of Liquor Licenses and Control
https://www.azliquor.gov DLLC USE ONLY

(602) 542-5141 sae ty (a OS

License #:

Title IV of the federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (the "Act"), 8 U.S.C. §
1621, provides that, with certain exceptions, only United States citizens, United States non-citizen nationals, non-
exempt "qualified aliens" (and sometimes only particular categories of qualified aliens), nonimmigrant, and certain
aliens paroled into the United States are eligible to receive state, or local public benefits. With certain exceptions, a
professional license and commercial license issued by a State agency is a State public benefit.

Arizona Revised Statutes § 41-1080 requires, in general, that a person applying for a license must submit documentation
to the license agency that satisfactorily demonstrates the applicant’s presence in the United States is authorized under
federal law.

Directions: All applicants must complete Sections |, II, and IV. Applicants who are not U.S. citizens or nationals
must also complete Section III.

Submit this completed form and a copy of one or more document(s) from the attached "Evidence of U.S. Citizenship,
U.S. National Status, or Alien Status" with your application for license or renewal. If the document you submit does
not contain a photograph, you must also provide a government issued document that contains your photograph. You

must submit supporting legal documentation (i.e. marriage certificate) if the name on your evidence is not the same
as your current legal name.

SECTION | — APPLICANT INFORMATION

APPLICANT NAME (rast ones) RYAN Witner Anderson

SECTION 11 — CITIZENSHIP OR NATIONAL STATUS

Are you a citizen or national of the United States? Yes [] No - if yes, indicate place of birth:

cay Pomona CA USA

State COUNTRY

If you answered Yes, 1) Attach a legible copy of a document from the list below.

Arizona Driver License

2) Nameof document:

If you answered No, you must complete Sections III.

5/5/2025 Page 1 of 3
Individuals requiring ADA accommodations please call (602)542-2999

EVIDENCE OF U.S. CITIZENSHIP, U.S. NATIONAL STATUS, OR ALIEN STATUS

You must submit supporting legal documentation (i.e. marriage certificate) if the name on your evidence is not
the same as your current legal name.

Evidence showing authorized presence in the United State includes the following:

1.

10.

12.

13.

5/5/2025

An Arizona driver license issued after 1996 or an Arizona non-operating identificationcard.

A driver license issued by a state that verifies lawful presence in the United States.

A birth certificate or delayed birth certificate showing birth in one of the 50 states, the District of Columbia,
Puerto Rico (on or after Jan. 13, 1941), Guam, the U.S. Virgin Islands (on or after January 17, 1917), American
Samoa, or the Northern Mariana Islands (on or after November 4, 1986, Northern Mariana Islands local time)

A United States certificate of birth abroad.

A United States passport. ***Passport must be signed***

A foreign passport with a United States visa.

An |-94 form with a photograph.

A United States citizenship and immigration services employment authorization document or refugee

travel document.

A United States certificate of naturalization.

A United States certificate of citizenship.

. A tribal certificate of Indian blood.

A tribal or bureau of Indian affairs affidavit of birth.

Any other license that is issued by the federal government, any other state government, an agency of this state
or a political subdivision of this state that requires proof of citizenship or lawful alien status before issuing the

license.

Page 20f3
Individuals requiring ADA accommodations please call (602)542-2999

\ SECTION II! — QUALIFIED ALIEN

Applisants who are not citizens or nationals of the United States. Please indicate alien status by checking the
appropNate box. Attach a legible copy of a document from the attached list or other document as evidence

of your status.

Name of document provided

Qualified Alien Stttus (8 U.S.C.§§ 1621(a)(1),-1641(b) and (c))
()1.An alien laws ully admitted for permanent residence under the Immigration and Nationality Act (INA)
C2.an alien who is granted asylum under Section 208 of the INA.
3.4 refugee admitted\o the United States under Section 207 of the INA.
Oa An alien paroled into the United States for at least one year under Section 212(d)(5) of theINA.
oO 5.An alien whose deportations being withheld under Section 243(h) of the INA.
[16.analien granted conditional enXxy under Section 203(a)(7) of the INA as in effect prior to April 1, 1980.
[(]7.An alien who is a Cuban/Haitian entrant.

([18.An alien who has, or whose child or chili's parent is a "battered alien" or an alien subject to extreme
cruelty in the United States

Nonimmigrant Status (8 U.S.C. § 1621(a)(2))

9. Anonimmigrant under the Immigration and NatioNeality Act [8 U.S.C § 1101 et seq.] Non-immigrants are
persons who have temporary status for a specific puNpose. See 8 U.S.C § 1101(a)(15).

Alien Paroled into the United States for Less Than One Year (8 \S.C. § 1621(a)(3))
10. An alien paroled into the United States for less than one yeaNunder Section 212(d)(5) of the INA

Other Persons (8 U.S.C § 1621(c)(2)(A) and (C)

11. A nonimmigrant whose visa for entry is related to employment in the\United States, or

12. Acitizen of a freely associated state, if section 141 of the applicable compact of free association approved
in Public Law 99-239 or 99-658 (or a successor provision) is in effect [Freel)\Associated States include the
Republic of the Marshall Islands, Republic of Palau and the Federate States of Nicronesia.

48 U.S.C. § 1901 etseq.];

13. A foreign national not physically present in the United States.
14. Otherwise Lawfully Present

15. A person not described in categories 1-13 who is ot ise lawfully present in the United State

pportunity Reconciliation Act may make persons
e 8 U.S.C. §

PLEASE NOTE: The federal Personal Responsibility and Wo
who fall into this category ineligible for |i

Ryan Witner Anderson

Print Name EE Signature Date
5/5/2025 Paige 3 of 3
Individuals requiring ADA Gecommodations please call (602}542-2999

05/11/2026

are 5 ed Lia, DER th AA

Arizona Department of Liquor Licenses and Control
https://www.azliquor.gov
(602) 542-5141

DLLC USE ONLY

lias WY SY
Peo
BU eaters

License # i)

Personal Information
Questionnaire

ATTENTION APPLICANT: This is a legally binding document. An investigation of your background will be
conducted. Incomplete applications will not be accepted. False or misleading answers may result in the denial or
revocation of a license or permit and could result in criminal prosecution.

THE COMPLETED QUESTIONNAIRE NEEDS TO BE SUBMITTED TO THE DEPARTMENT ALONG WITH A $22. FEE, AND FD-258
FINGERPRINT CARD, THAT HAS BEEN SEALED IN AN ENVELOPE, AND SIGNED OR INITIALED BY THE FINGERPRINT TECHNICIAN, MUST
INCLUDE THE FINGERPRINT VERIFICATION FORM. MUST BE COMPLETED BY A RECOGNIZED FINGERPRINT SERVICE OR LAW

ENFORCEMENT AGENCY.

Agent: a person who
is designated by an
applicant or licensee
to receive
communications from
the department and to
file and sign
documents submitted
to the department on
behalf of the applicant
or licensee. An agent
is not a manager.

|LA.R.S. §4-202(4)

Controlling Person:
person directly or
indirectly possessing
control of an applicant
or licensee.

AR.S. §4-101/10).

Manager: An

individual (not an
entity) approved by
the Department of
Liquor who has the
authority to organize,
direct, carry out,
control or to
otherwise operate the
day-to-day operations
of a liquor-licensed
business.

A.R.S. §4-101(22) and
A.A.S. §4-202{C)

5/5/2025

SECTION - 1 INDIVIDUAL INFORMATION

Cacent [IcONTROLLING PERSON [1] MANAGER
1. Name: Cadieux || Chester Edouard
Last First Middle
2. Social Security ii Birth Date:

(NOT a public record)

d: OK

(NOT a public record)
State Issue

Date of residency: ff

3. Driver's License
(NOT a public record)

5. Are you a resident of Arizona? LJYes [No
6. Email address; TS
7. Home Address: i Ls SG

8. Daytime phone #: hth W Alternative phone [/ iW

SECTION 2 — LICENSED BUSINESS INFORMATION

1. License Number:

2. Business Name (doing business as): QuikTrip #491

350 N Jackrabbit Trail, Buckeye AZ 85326

3. Business Address:

Page 1of2

"oo 3 Gi} Ligv. Dept Aig 5g
SECTION 3 — DAY TO DAY OPERATION OF BUSINESS

Must attach copies of Basic and Management Title 4 training certificates for person managing the day to day
operation of the licensed business.

Who is managing the day to day operations? [hgent Ccontrolling Person [¥]Manager

Name of persons who will be handling the day to day operations: wis ase

SECTION 4 —- BACKGROUND

If you answer “YES” to any Question 1 through S YOU MUST attach a signed statement. Give complete details including
dates, agencies involved and dispositions. CHANGES TO QUESTIONS 1-5 MAY NOT BE ACCEPTED

1. Have you owned, or been a controlling person of any entities that held a liquor Yes No []
license in Arizona, or any jurisdiction, in the past 5 years?

2. Have you been cited, arrested, indicted, convicted, or required to appear in Yes [-[] No
court for violation of ANY criminal law or ordinance, regardless of the
disposition, even if dismissed or expunged, within the past 5 years?

3. Has an entity in which you are or have been a controlling person had an Yes [[] No
application or license rejected, denied, revoked, or suspended in or outside of
Arizona within the last 5 years? A.R.S.§4-202(D

4. Have you had ANY administrative law citations, compliance actions, or Yes [[] No
consents, in any jurisdiction in the past 5 years? (Do not include civil traffic
tickets)

A.R.S.§4-202,4-210
“Administrative Law Violations are any civil penalties, fines, suspension,
or revocations of your liquor license.

5. Has anyone EVER obtained a judgement against you the subject of which Yes [] No
involved fraud or misrepresentation?

SIGNATURE

1, (Print Full Name) Chester Edouard Cadieux III hereby swear under penalty of perjury and in

compliance with A.R.S. § 4-210(A)(2) and (3) that | have read and understand the foregoing and verify that
the information and statements that | have made herein are true and correct to the best of my knowledge.

05/11/2026
Date:

Signature:

5/5/2025 Page 2 of 2

Chester Cadieux III - Statement for Section 4 Background

Question #1 on Personal Questionnaire:

am one of the controlling people for the following

QUIKTRIP #1426
QUIKTRIP #1434
QUIKTRIP #1460
QUIKTRIP #1417
QUIKTRIP #1431

QUIKTRIP #1468
QUIKTRIP #1474
QUIKTRIP # 1428
QUIKTRIP # 1452
QUIKTRIP # 1456
QUIKTRIP # 1464
QUIKTRIP # 471

QUIKTRIP # 488

QUIKTRIP #1400
QUIKTRIP #1401

QUIKTRIP #1402
QUIKTRIP #1403

QUIKTRIP #1404
QUIKTRIP #1405
QUIKTRIP #1406
QUIKTRIP #1407

QUIKTRIP #1408
QUIKTRIP #1409
QUIKTRIP #1410
QUIKTRIP #1411

QUIKTRIP #1412
QUIKTRIP #1413

QUIKTRIP #1415

QUIKTRIP #1416
QUIKTRIP #1418
QUIKTRIP #1419
QUIKTRIP #1420
QUIKTRIP #1421

QUIKTRIP #1422
QUIKTRIP #1423

QUIKTRIP #1424
QUIKTRIP #1425
QUIKTRIP #1427
QUIKTRIP #1429

liquor licenses:

AZ License #
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010070023530
010070026005
10103524
010070018694
010070018763
010100018762
010100018693
10076277
10103529
10103536
10103710
10075251
10076707
10076079
10075880
010070012636
10076797
10076091
010070022711
10076868
010070004515
10076086
010070012539
010070012540
10075779
010070011903
010070033401
010070011904
010070011902
010070017276
010070023272
10076045
010070032980
010070012412
010070024772
10076651
010070013285
010070014417
010070024771

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QUIKTRIP #1430
QUIKTRIP #1432
QUIKTRIP #1433
QUIKTRIP #1435
QUIKTRIP #1437
QUIKTRIP #1438
QUIKTRIP #1439
QUIKTRIP #1441
QUIKTRIP #1444
QUIKTRIP #1447
QUIKTRIP #1449
QUIKTRIP #1450
QUIKTRIP #1453
QUIKTRIP #1454
QUIKTRIP #1461
QUIKTRIP #1463
QUIKTRIP #1469
QUIKTRIP #1470
QUIKTRIP #1475
QUIKTRIP #1476
QUIKTRIP #1479
QUIKTRIP #1480
QUIKTRIP #1482
QUIKTRIP #1483
QUIKTRIP #1487
QUIKTRIP #1490
QUIKTRIP #1491
QUIKTRIP #1492
QUIKTRIP #1493
QUIKTRIP #1496
QUIKTRIP #1499
QUIKTRIP #1502
QUIKTRIP #1503
QUIKTRIP #1505
QUIKTRIP #1507
QUIKTRIP #1523
QUIKTRIP #1549
QUIKTRIP #400

QUIKTRIP #401

QUIKTRIP #402

QUIKTRIP #403

QUIKTRIP #404

QUIKTRIP #405R
QUIKTRIP #406

AZ License #
AZ License #
AZ License #
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AZ License #
AZ License #
AZ License #
AZ License #
AZ License #
AZ License #
AZ License #
AZ License #
AZ License #
AZ License #
AZ License #
AZ License #
AZ License #

010070030691
010070012538
010070014528
010070011905
010070017274
010070026004
010070023528
010070013760
010070022770
010070022769
010070023527
10103525
10103527
10103603
10103647
10103733
010100011901
10103591
10103614
10103653
10103639
010100021877
10103516
10103656
10103601
10103530
010100013271
10103543
10103528
10103605
010100023365
010070033517
010070032982
010110033400
010070030348
010070032885
010130032983
10074236
10073816
10073959
010070030392
10074367
10076429
10073892

QUIKTRIP #407
QUIKTRIP #408
QUIKTRIP #409
QUIKTRIP #410
QUIKTRIP #411
QUIKTRIP #412
QUIKTRIP #413
QUIKTRIP #414
QUIKTRIP #415
QUIKTRIP #416
QUIKTRIP #417
QUIKTRIP #418
QUIKTRIP #419R
QUIKTRIP #420
QUIKTRIP #421
QUIKTRIP #422
QUIKTRIP #423
QUIKTRIP #424
QUIKTRIP #425
QUIKTRIP #426
QUIKTRIP #427
QUIKTRIP #429
QUIKTRIP #430
QUIKTRIP #431R
QUIKTRIP #432
QUIKTRIP #433
QUIKTRIP #434
QUIKTRIP #435
QUIKTRIP #436
QUIKTRIP #437
QUIKTRIP #438
QUIKTRIP #439
QUIKTRIP #440
QUIKTRIP #441
QUIKTRIP #442
QUIKTRIP #443
QUIKTRIP #444
QUIKTRIP #445
QUIKTRIP #446
QUIKTRIP #447
QUIKTRIP #448
QUIKTRIP #449R
QUIKTRIP #450
QUIKTRIP #451

AZ License #
AZ License #
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AZ License #
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AZ License #
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10073986
10074140
10074620
10075655
10074950
10074402
10074224
10075742
010070022476
10073933
10074784
10075500
10076524
10075572
10075590
10074759
10076650
010070017275
10074621
10073960
10074327
10074873
10073932
010070004514
10076260
10075145
10075111
10074513
10076625
10113143
10073875
10074578
10073972
10074358
10075775
10076353
10074819
10075622
10074069
10074760
10074380
10076784
010070013036
10073818

QUIKTRIP #452
QUIKTRIP #453
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QUIKTRIP #456
QUIKTRIP #457
QUIKTRIP #458
QUIKTRIP #459
QUIKTRIP #460
QUIKTRIP #461
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QUIK TRIP #479
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QUIKTRIP #485
QUIKTRIP #486
QUIKTRIP #487
QUIKTRIP #489
QUIKTRIP #490R
QUIKTRIP #492
QUIKTRIP #493
QUIKTRIP #494
QUIKTRIP #495
QUIKTRIP #496
QUIKTRIP #497R
QUIKTRIP #499
QUIKTRIP #1548
QUIKTRIP #1518
QUIKTRIP #1436

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10074584
10075180
10076071
10073817
10074295
10073840
10075179
10076080
10073815
10074817
010070024044
010070023271
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10075780
10075082
10074449
010070032884
10075595
10113293
010070001682
10073853
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010110014910
10076525
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09110001
10075083
10076437
10113120

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010070036197

010070036425

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QuikTrip Liquor Licenses (All of USA)

Alabama 8
Arkansas 3
Colorado 21
Georgia 178
Illinois 17
Indiana 1
Iowa 20
Kansas 77
Louisiana 4
Mississippi 9
Missouri 139
Nebraska 15
Nevada 1
North Carolina 42
Ohio 1
Oklahoma 88
South Carolina 79
Tennessee 7
Texas 301

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Arizona Department of Liquor Licenses and Control
https://www.azliquor.gov
(602) 542-5141

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Personal Information
Questionnaire

License #

conducted. Incomplete applications will not be accepted. False or misleading answers may result in the denial or
revocation of a license or permit and could result in criminal prosecution.

THE COMPLETED QUESTIONNAIRE NEEDS TO BE SUBMITTED TO THE DEPARTMENT ALONG WITH A $22. FEE, AND FD-258
FINGERPRINT CARD, THAT HAS BEEN SEALED IN AN ENVELOPE, AND SIGNED OR INITIALED BY THE FINGERPRINT TECHNICIAN, MUST
INCLUDE THE FINGERPRINT VERIFICATION FORM. MUST BE COMPLETED BY A RECOGNIZED FINGERPRINT SERVICE OR LAW

ENFORCEMENT AGENCY.

Agent: a person who
is designated by an
applicant or licensee
to receive
communications fram
the department and to
file and sign
documents submitted
to the department on
behalf of the applicant
or licensee, An agent
is not a manager.

[AR.S. §4-202(A).

Controlling Person:
person directly or
indirectly possessing
control of an applicant
or licensee.

A.R.S. §4-101(10).

Manager: An

individual (not an
entity) approved by
the Department of
Liquor who has the
authority to organize,
direct, carry out,
control or to
otherwise operate the
day-to-day operations
of a liquor-licensed
business.

A.R.S. §4-101(22) and

A.R.S. §4-202(C)

5/5/2025

SECTION - 1 INDIVIDUAL INFORMATION

CaGent CIconTROLUNG PERSON MANAGER
1. Name:_ Serrano Cynthia Navarrete
last First Middle

Birth Date:

(NOT a public record)
State Issued: AZ

Date of residency: 05 01 /2005_

2. Social Security 7 )0|6lUl

{NOT a public record)
006462332

3. Driver’s License #:
(NOT a public record)

S. Are you a resident of Arizona? _(V]Yes [No
6. Email address: fF
7. Home Address: i
8. Daytime phone #: | kell Alternative phone #: cr ==

SECTION 2 —LICENSED BUSINESS INFORMATION

1. License Number:

2. Business Name (doing business as): QuikTrip #491

3. Business Address; _____350 N Jackrabbit Trail Buckeye AZ 85326

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Individuals requiring ADA accommodations please call {602)542-2999