#401614 Harkins Verrado Marketplace-Redacted.pdf
Extracted text (via ocr_local)
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Received in the Buckeye City Clerk's office June 16, 2026 at 4:15 p.m. by LCA
State of Arizona
Department of Liquor Licenses and Control
Created 06/16/2026 @ 01:49:15 PM
Local Governing Body Report
LICENSE
Number: 06070129 Type: 006 BAR
Name: HARKINS VERRADO MARKETPLACE
State: Pending
Issue Date: Expiration Date: 01/31/2027
Original Issue Date: 04/13/1962
Location: 1515 N VERRADO WAY
BUCKEYE, AZ 85396
USA
Mailing Address:
PHOENIX, AZ 85004
USA
Phone: Fe
Alt. Phone:
Email: Pe
Currently, this license has pending applications.
AGENT
Name: ANDREA DAHLMAN LEWKOWITZ
Gender: Female
Correspondence Address:
PHOENIX, AZ 85004
USA
Phone: Pe
Alt. Phone:
Email: Pe
OWNER
(covnclay
0%-|S- 20s
Page | of 7
Name: HARKINS BUCKEYE LLC
Contact Name: ANDREA DAHLMAN LEWKOWITZ
Type: LIMITED LIABILITY COMPANY
AZ CC File Number: 23738751 State of Incorporation: AZ
Incorporation Date: 10/10/2024
Correspondence Address:
PHOENIX, AZ 85004
USA
Alt. Phone:
Email: Pe
Officers / Stockholders
Name: Title: % Interest:
HARKINS INVESTMENTS LLC Member 100.00
HARKINS ENTERPRISES INC - CFO/SVP/TREAS
HARKINS ADMINISTRATIVE SERVICES INC -
CFO/SVP/TREAS
RED'S AMUSEMENT INC - CFO/SVP/TREAS
Name: TYLER STEPHEN COOPER
Gender: Male
Correspondence Address:
PHOENIX, AZ 85004
USA
Phone: a
Alt. Phone:
Email es
DKH TRUST EST UNDER HARKINS CHILDRENS
TRUST UTD 8/1/94 - Trustee
JMH TRUST EST UNDER HARKINS CHILDRENS
TRUST UTD 8/1/1994 - TRUSTEE
Name: GRETA JANE NEWELL
Gender: Female
Correspondence Address:
PHOENIX, AZ 85004
USA
Alt. Phone:
Email: es
Page 2 of 7
RED'S AMUSEMENT INC - Shareholder
Name: DANIEL E HARKINS TRUST UTD 12/26/20
Contact Name: ANDREA LEWKOWITZ
Type: TRUST
AZ CC File Number: State of Incorporation:
Incorporation Date:
Correspondence Address: Fm
USA
Alt. Phone:
Email: es
HARKINS ADMINISTRATIVE SERVICES INC -
Shareholder
Name: RED'S AMUSEMENT INC
Contact Name: ANDREA LEWKOWITZ
Type: CORPORATION
AZ CC File Number: State of Incorporation:
Incorporation Date:
Correspondence Address:
PHOENIX, AZ 85004
USA
Alt. Phone:
Email: es
HARKINS INVESTMENTS LLC - Member
Name: DKH TRUST EST UNDER HARKINS CHILDRENS TRUST UTD 8/1/94
Contact Name: ANDREA LEWKOWITZ
Type: TRUST
AZ CC File Number: State of Incorporation:
Incorporation Date:
Correspondence Address:
SCOTTSDALE, AZ 85250
USA
Alt. Phone:
Email: PC )
DANIEL E HARKINS TRUST UTD 12/26/20 - Trustee
Name: DANIEL EARL HARKINS
Gender: Male
Correspondence Address:
PHOENIX, AZ 85004
USA
Alt. Phone:
Email: es
Page 3 of 7
HARKINS INVESTMENTS LLC - Managing Member
Name: HARKINS ENTERPRISES INC
Contact Name: ANDREA LEWKOWITZ
Type: CORPORATION
AZ CC File Number: State of Incorporation:
Incorporation Date:
Correspondence Address:
PHOENIX, AZ 85004
USA
Alt. Phone:
Email: |)
HARKINS ENTERPRISES INC - COO/EVP
HARKINS ADMINISTRATIVE SERVICES INC -
COO/EVP
RED'S AMUSEMENT INC - COO/EVP
Name: RACHEAL RIGGS WILSON
Gender: Female
Correspondence Address:
PHOENIX, AZ 85004
USA
Alt. Phone:
HARKINS BUCKEYE LLC - Member
Name: HARKINS INVESTMENTS LLC
Contact Name: ANDREA LEWKOWITZ
Type: LIMITED LIABILITY COMPANY
AZ CC File Number: State of Incorporation:
Incorporation Date:
Correspondence Address:
PHOENIX, AZ 85004
USA
Alt. Phone:
Emil ee)
Page 4 of 7
HARKINS ENTERPRISES INC - CEO/President
HARKINS ADMINISTRATIVE SERVICES INC -
CEO/President
RED'S AMUSEMENT INC - CEO/President
Name: MICHAEL LEE BOWERS
Gender: Male
Correspondence Address:
PHOENIX, AZ 85004
USA
Phone: fF
Alt. Phone:
Emil: es
HARKINS ENTERPRISES INC - Chairman
RED'S AMUSEMENT INC - Chairman
HARKINS ADMINISTRATIVE SERVICES INC -
Chairman
Name: DANIEL EARL HARKINS
Gender: Male
Correspondence Address:
PHOENIX, AZ 85004
USA
Alt. Phone:
Email: es
HARKINS ENTERPRISES INC - Secretary
RED'S AMUSEMENT INC - Secretary
HARKINS ADMINISTRATIVE SERVICES INC -
Secretary
Name: MICHAEL ALLEN MCCAULEY
Gender: Male
Correspondence Address:
PHOENIX, AZ 85004
USA
Alt. Phone:
Email: es
Page 5 of 7
HARKINS INVESTMENTS LLC - Member
Name: JMH TRUST EST UNDER HARKINS CHILDRENS TRUST UTD 8/1/1994
Contact Name: ANDREA LEWKOWITZ
Type: TRUST
AZ CC File Number: State of Incorporation:
Incorporation Date:
Correspondence Address:
SCOTTSDALE, AZ 85250
USA
Alt. Phone:
Email: es
MANAGERS
Name: HARKINS ADMINISTRATIVE SERVICES INC
Contact Name: ANDREA LEWKOWITZ
Type: LIMITED LIABILITY COMPANY
AZ CC File Number: State of Incorporation:
Incorporation Date:
Correspondence Address:
PHOENIX, AZ 85004
USA
Alt. Phone:
Email es
APPLICATION INFORMATION
Application Number: 401614
Application Type: Location / Owner Transfer
Created Date: 06/02/2026
QUESTIONS & ANSWERS
006 Bar
1) Are you applying for an Interim Permit (INP)?
No
3) Does the Business location address have a street address for a City or Town but is actually in the
boundaries of another City, Town or Tribal Reservation?
No
11) Provide name, address, and distance of nearest school. (If less than one (1) mile note footage)
Sequoia Pathfinder Academy at Verrado Way & I-10 Elementary | 1,780 FT
20370 West Roosevelt St, Buckeye, AZ 85326
Page 6 of 7
12) Are you one of the following? Please indicate below.
Property Tenant
Sub-tenant
Property Owner
Property Purchaser
Property Management Company
PROPERTY TENANT
13) Is there a penalty if lease is not fulfilled?
Yes
What is the penalty?
TERMINATION AND/OR OTHER MONETARY PENALTIES
14) What is the total money borrowed for the business not including the lease?
Please list lenders/people owed money for the business.
0.00
15) Is there a drive through window on the premises?
No
16) If there is a patio please indicate contiguous or non-contiguous within 30 feet.
NO PATIO
17) Is your licensed premises now closed due to construction, renovation or redesign or rebuild?
Yes
If yes, what is your estimated completion date?
NOVEMBER 2026
18) Total Price paid for Series 6 Bar, Series 7 Beer & Wine Bar or Series 9 Liquor Store (license only)
TBD
DOCUMENTS
DOCUMENT TYPE FILE NAME UPLOADED DATE
MISCELLANEOUS Harkins Buckeye, L.L.C._Ownership 06/02/2026
chart.pdf
BILL OF SALE Section 5_SIGNED.pdf 06/02/2026
ALIEN STATUS Verrado_AGT ADL (Ctn).pdf 06/02/2026
QUESTIONNAIRE Verrado_AGT ADL (Q).pdf 06/02/2026
BILL OF SALE Verrado_Assignment of 06/02/2026
LL_SIGNED.pdf
QUESTIONNAIRE Verrado_CP Bowers (Q+Supple).pdf 06/02/2026
QUESTIONNAIRE Verrado_CP Cooper _(Q+Supple).pdf 06/02/2026
QUESTIONNAIRE Verrado_CP Harkins (Q+Supple).pdf 06/02/2026
QUESTIONNAIRE Verrado_CP McCauley (Q+Supple).pdf 06/02/2026
QUESTIONNAIRE Verrado_CP Newell (Q+Supple).pdf 06/02/2026
QUESTIONNAIRE Verrado_CP Wilson (Q+Supple).pdf 06/02/2026
DIAGRAM/FLOOR PLAN Verrado_Diagram.pdf 06/02/2026
Page 7 of 7
"OB 6
Harkins Buckeye, L.L.C.
S Liqr, Dept An TiS
Ownership Chart | 05/15/2026
DKH Trust Est. under
Harkins Children’s Trust
U/T/D - 8/1/94
Trustee: Greta Newell*
Harkins Administrative Services, Inc
Harkins Enterprises, Inc. +
Red’s Amusement, Inc.
( Officers)
Michael Bowers, CEO/Pres
Daniel Harkins, Chairman
Racheal Wilson, COO/EVP
Tyler Cooper, CFO/SVP/Treas
Michael McCauley, Secretary
Member (42.5%)
8901 E. McDonald Drive
Scottsdale, AZ 85250
No one owns 10% or more of
the Licensee
Harkins Enterprises, Inc.
Manager/Member (15%)
8901 E. McDonald Drive
Scottsdale, AZ 85250
JMH Trust Est. under
Harkins Children’s Trust
U/T/D - 8/1/1994
Trustee: Greta Newell
Member (42.5%)
8901 E. McDonald Drive
Scottsdale, AZ 85250
Daniel E. Harkins
Trust U/T/D 12/26/20
Trustee: Daniel Harkins
Shareholder (100%)
8901 E. McDonald Drive
Scottsdale, AZ 85250
Harkins Investments, LLC
Member (100%)
8901 E. McDonald Drive
Scottsdale, AZ 85250
l
Red’s Amusement, Inc.
Shareholder (100%)
8901 E. McDonald Drive
Scottsdale, AZ 85250
HARKINS BUCKEYE, L.L.C.
Applicant
Harkins Administrative
Services, Inc.
Manager
8901 E. McDonald Drive
Scottsdale, AZ 85250
fw
26 6 3 Lig Beet at 7 x,
ASSIGNMENT OF LIQUOR LICENSE
For good and valuable consideration, the receipt and sufficiency of which is hereby
acknowledged, Harkins Estrella Falls, L.L.C., an Arizona limited liability company
(“Assignor”), hereby assigns, conveys, and transfers to Harkins Buckeye, L.L.C. an Arizona
limited liability company (“Buyer”), all right, title, and interest in and to Arizona Liquor License
no. 06070129 (the “License”’).
Assignor warrants it is the lawful owner of the License, the License is free and clear of all
taxes, liens, encumbrances, and claims except for inactive fees which may be due to the Arizona
Dept. of Liquor Licenses & Control when the License is issued and activated by Assignee, and
the undersigned is authorized to execute all documents necessary to assign the License on behalf
of Assignor.
This Assignment shall be binding upon Assignor, its successor and assigns, and shall
inure to the benefit of Assignee, its successors, and assigns.
Harkins Estrella Falls, L.L.C.,
an Arizona limited liability company,
By: Harkins Administrative Services, Inc.,
Th... its manager
By a eae
tts__CFO g5UP |
STATE OF nitens )
)
County of Manu px )
SUBSCRIBED AND SWORN to before me this 2 # day of May , 2026,
by Thuy Caper g
My Commission Expires: August Il, 2077 B, ;
(Notary Public
/
ACCEPTED:
BREON JOHNSON |
ea Notary Public - State of Arizona {
ey MARICOPA COUNTY
47 Commission # 687591
Expires August 11, zi |
Harkins Buckeye, L.L.C.,
an Arizona limited liability company,
By: Harkins Administrative Services, Inc.,
an Arizona corporation, its manager
O66 3 lig dept wt Toe
SECTION 4- Organization
UST SUBMIT A PERSONAL QUESTIONNAIRE FORM, FINGERPRINT CARD, AND $22 PROCESSING FEE PER CARD.
not an individual, answer questions A and B.
State where Incorporated/Organized:
Approval Date:
1. If the applicant is an en
A) Date Incorporated/Orga
B) AZ Corporation or AZL.L.C. Entity
2. List any individual or entity that owns interest o!
owns another entity, MUST attach a statement which
or more, and/or has control. If the owner/member listed below
des the liquor license number involved.
Complete Mailing Address
Si
Name Title
i
SECTION 5 - Person to Person Transfer
ARS§4-203(C), (D), (G) (Current owner information)
1. License #; 06070129
2. Agent Name: Andrea Dahiman Lewkowitz
3. Entity Name: Harkins Estrella Falis, LLC
4. Business Name: ‘arkins Theatres at Estrella Falls
5. Business Address: 15010 W. McDowell Road, Goodyear, AZ 85395
6. Does current licenses intend to operate the business while this application is ee ae
a <a
Print Licensee Name: [uu Ax PICCHLEY Signature: ‘ahem
SECTION 6 - Location Transfer
ARS§4-203(C), (D}, (G) (Current owner information)
1. License #; _ 06070129
2. Current Business: Name: Harkins Theatres at Estrella Falls
Address: 19010 W. McDowell Road, Goodyear, AZ 85395
3. New Business: Name: Harkins Verrado Marketplace
Address: 1515 N. Verrado Way, Buckeye, AZ 85396
05/05/2025 Page 201 4
Individuals requiring ADA accommodations please call (602)542-2999
HARKINS VERRADO MARKETPLACE
1515 N. Verrado Way
Buckeye, AZ 85396
First Floor: 68,988 SF | Mezzanine Floor: 6,918 SF
First Floor
KITCHEN
DINING
fl
ne
8
LIQUOR STORAGE DINING A= ENTRANCE/EXITS
DININ'
TEL wt yaar) £9 Fes
HARKINS VERRADO MARKETPLACE
Mezzanine Level :
4
| i hes ‘ian
it} ia = of aa en Sa
@ sr Oe beg
—. - a
= _ sf a — _ s
Tig water EB 8 U2.
"ch & 3 Lig. beet aH THe
Arizona Department of Liquor Licenses and Control
https://www.azliquor.gov DLLC USE ONLY
(602) 542-5141 Job #: Yo | (p { Y
0-10-20
Personal Information New
oO 6-
(FTGOIMOI.29
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.
L — J
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 ORINITIALED BY THE FINGERPRINT TECHNICIAN, MUST
INCLUDE THE FINGERPRINT VERIFICATION FORM. MUST BE COMPLETED BY A RECOGNIZED FINGERPRINT SERVICE OR LAW
ENFORCEMENT AGENCY. FP Cru ent 06-25-2027
Agent: a person who
Eeeeennye SECTION - 1 INDIVIDUAL INFORMATION
applicant or licensee
to receive
communications from
the department and to Macent LIcONTROLLING PERSON -EFMANAGER
file and sign
documents submitted
tothe departmenton [14 jame:__LEWKOWITZ ANDREA DAHLMAN
behalf of the applicant Last First Middte
or licensee. An agent . ‘ : F . : ——~SY
# hata mendeer: 2. Social Security # Birth Date:
(NOT a public record) (NOT a public record)
ARS. §4-202(A). 3. Driver's License +: State Issued: “©
{NOT a public record)
Controlling Person: 5, Are you aresident of Arizona? [X]lYes [INo Date of residency: °4 / 9 / 196!
person directly or
control of an applicant
A.R.S. §4-101(20).
8. Daytime phone #:__SM Alternative phone #:
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.
SECTION 2 — LICENSED BUSINESS INFORMATION
06070129 | PENDING
1. License Number:
HARKINS VERRADO MARKETPLACE
2. Business Name (doing business as):
. 1515 N. VERRADO WAY, BUCKEYE, AZ 85396
3. Business Address: —~-- -- ES A Se
A.R.S. §4-101(22) and
A.R.S. §4-202(C)
5/5/2025 Page 1 of 2 UC-GEN-QUEST-001
individuals requiring ADA accommodations please call (602)542-2999
5G J Lig beet at Pte
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? CIagent Licontrolling Person Manager
Name of persons who will be handling the day to day operations: PENDING
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 beena 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 {x]
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) ANDREA DAHLMAN LEWKOWITZ hereby swear under penalty of perjury and in
compliance with A.R.S. § 4-240(A)(2) and (3) that | have read and understand the foregoing and verify that
the nr W statements that | have made herein are true and correct to the best of my knowledge.
Signature: Date: 29/15/2026
Ae iG
5/5/2025 Page 2 of 2 LIC-GEN-QUEST-00|
individuals requiring ADA accommodations please call (602)542-2999
66S tig, dept a 7 ie
Arizona Department of Liquor Licenses and Control
https://www.azliquor.gov DILC USE ONLY
(602) 542-5141 MELO (plY
D epted: a
ALIEN STATUS OTe 202U d
‘Ou
S67 0124
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 I, Il, and IV. Applicants who are not U.S. citizens or nationals
must also complete Section Ill.
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 photogra: ‘ou must also provi rnment 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 (Print ortype) ANDREA DAHLMAN LEWKOWITZ
SECTION II — CITIZENSHIP OR NATIONAL STATUS
Are you a citizen or national of the United States? [X] yes O No - If yes, indicate place of birth:
City MANKATO State MN country USA
If you answered Yes, 1) Attach a legible copy of a document from the list below.
2) Nameof document: __AZ DRIVER LICENSE
If you answered No, you must complete Sections III.
5/5/2025 Page 1 of 3 LIC-GEN-ALIENSTAT-001
Individuals requifing 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. An Arizona driver license issued after 1996 or an Arizona non-operating identificationcard.
2. Adriver license issued by a state that verifies lawful presence in the United States.
3. 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)
4, AUnited States certificate of birth abroad.
5. AUnited States passport. *** Passport must be signed***
6. A foreign passport with a United States visa.
7. An1-94 form with a photograph.
8. A United States citizenship and immigration services employment authorization document or refugee
travel document.
9. AUnited States certificate of naturalization.
10. A United States certificate of citizenship.
11. A tribal certificate of Indian blood.
12. A tribal or bureau of Indian affairs affidavit of birth.
13. Any other license that is issued by the federal government, any other state government, an agency of this state
ora political subdivision of this state that requires proof of citizenship or lawful alien status before issuing the
license.
5/5/2025 Page 2 of 3 LIC-GEN-ALIENSTAT-001
Individuals requiring ADA accommodations please call (602)542-2999
Applicants who are not citizens or nationals of the United States. Please indicate alien status by checking the
appropriate 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 Status (8 U.S.C.§§ 1621(a)(1),-1641(b) and (c})
[)1.an alien lawfully admitted for permanent residence under the Immigration and Nationality Act(INA)
C12.an alien who is granted asylum under Section 208 of the INA.
O3.a refugee admitted to the United States under Section 207 of the INA.
C4 analien paroled into the United States for at least one year under Section 212(d)(5) of thelNA.
C15.An alien whose deportation is being withheld under Section 243(h) of the INA.
(16.an alien granted conditional entry under Section 203(a)(7) of the INA as in effect prior to April 1, 1980.
(17.an alien who is a Cuban/Haitian entrant.
oO 8.An alien who has, or whose child or child'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 Nationality Act [8 U.S.C § 1101 et seq.] Non-immigrants are
persons who have temporary status for a specific purpose. See 8 U.S.C § 1101(a)(15).
Alien Paroled into the United States for Less Than One Year (8 U.S.C. § 1621(a)(3))
10. An alien paroled into the United States for less than one year under 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 [Freely Associated States include the
Republic of the Marshall Islands, Republic of Palau and the Federate States of Micronesia.
48 US.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 otherwise lawfully present in the United States.
PLEASE NOTE: The federal Personal Responsibility and Work Opportunity Reconciliation Act may make persons
ANDREA DAHLMAN LEWKOWITZ
5/15/2026
5/5/2025
Date
LIC-GEN-ALIENSTAT-001
Print Name
Individuals requiing ADA accommodations please call (602}542-2999
"ch 6 F tian wept at 72
Arizona Department of Liquor Licenses and Control
https://www.azliquor.gov
(602) 542-5141
‘eb YO/ (014
ir
{HtN0124
D
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)
| 3. Driver’s License #;
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
oo
A.R.S. §4-202(C)
5/5/2025
Fe Crarrent 0F-9F 202F
SECTION - 1 INDIVIDUAL INFORMATION
FP: 8/2024
LJacent VIcONTROLLING PERSON [-] MANAGER
1. Name: BOWERS MICHAEL LEE
last First Middle
2. Social Security Iii
(NOT a public record)
Birth Cate
(NOT a public record)
State Issued: AZ
(NOT a public record)
5. Are you a resident of Arizona? (Z]Yes [No Date ofresidency: 12/31 1977
6. Email address: reas
7. Home Address a PO }
8. Daytime phone Cl Alternative phone id
SECTION 2 — LICENSED BUSINESS INFORMATION
16070129 | PENDING
1. License Number: Dee PEE
2. Business Name (doing business as): HARKINS VERRADO MARKETPLACE
1515 N. VERRADO WAY, BUCKEYE, AZ 85396
3. Business Address:
Page 1 of 2 LIC-GEN-QUEST-001
Individuals requiring ADA accommodations please call (602) 542-2999
ch 6 OF Liq feet aoe
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? Cogent Controlling Person [¥]Manager
Name of persons who will be handling the day to day operations: PENGRNs
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 [-_] 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
I, (Print Full Name) MICHAEL LEE BOWERS 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 ts that | have made herein are true and correct to the best of my knowledge.
Signature: i Date: 4/) | 202¢
5/5/2025 Page 2 of 2 LIC-GEN-QUEST-001
Individuals requiring ADA accommodations please call (602)542-2999