Circle K #9615 Redacted Application.pdf

Received in the Buckeye City Clerk's office April 27, 2026 at 9:00 a.m. by LCA

State of Arizona
Department of Liquor Licenses and Control

Created 04/17/2026 @ 11:55:07 AM
Local Governing Body Report

LICENSE

Number: 09070182 Type: 009 LIQUOR STORE
Name: CIRCLE K STORE #9615
State: Pending
Issue Date: Expiration Date: 12/31/2026
Original Issue Date: 11/18/1982
Location: 23900 W BROADWAY ROAD

BUCKEYE, AZ 85326

USA

PHOENIX, AZ 85072-2085
USA

Phone:
Alt. Phone:

Currently, this license has pending applications.

AGENT

Name: MARIA DANIELLE BURGESS
Gender: Female

PHOENIX, AZ 85072-2085
USA

Phone:
Alt. Phone:
Email:

OWNER

los Noy

(, \\w- Bo>'o

Page 1 of 6

Name: CIRCLE K STORES INC

Contact Name: MARIA DANIELLE BURGESS

Type: CORPORATION

AZ CC File Number: F00065980 State of Incorporation: AZ
Incorporation Date: /08/

Correspondence Address:

PHOENIX, AZ 85072-2085

USA
Phone:
Alt. Phone:
Email:
Officers / Stockholders
Name: Title: % Interest:
CIRCLE K DELAWARE INC Stockholder 100.00
MARIA DANIELLE BURGESS Asst. Secretary
KATHLEEN K CUNNINGTON President,Sec, Treas, Director
EDILBERTO QUINTANA Vice President
CIRCLE K STORES INC - Stockholder
Name: CIRCLE K DELAWARE INC
Contact Name: MARIA DANIELLE BURGESS
Type: CORPORATION
AZ CC File Number: State of Incorporation:
Incorporation Date:

Correspondence Address:

PHOENIX, AZ 85072-2085

USA

Alt. Phone:
COUCHE TARD INC - Stockholder

Name: DEPAN ESCOMPTE COUCHE TARD INC
Contact Name: MARIA DANIELLE BURGESS
Type: CORPORATION
AZ CC File Number: State of Incorporation:
Incorporation Date:
Correspondence Address: P|

PHOENIX, AZ 85072

USA
Alt. Phone:

Page 2 of 6

DEPAN ESCOMPTE COUCHE TARD INC -

Stockholder
Name: ALIMENTATION COUCHE TARD INC
Contact Name: MARIA DANIELLE BURGESS
Type: CORPORATION
AZ CC File Number: State of Incorporation:

Incorporation Date:
Correspondence Address:

PHOENIX, AZ 85072
USA

Phone:
Alt. Phone:
Email:

ALIMENTATION COUCHE TARD INC - Senior Vice
President
DEPAN ESCOMPTE COUCHE TARD INC - VP
COUCHE TARD INC - VP
MACS CONVENIENCE STORES INC - VP
COUCHE TARD US INC - Pres/SEC
CIRCLE K CORPORATION - Pres/SEC
CIRCLE K DELAWARE INC - Pres/SEC
CIRCLE K STORES INC - President,Sec, Treas,
Director
Name: KATHLEEN K CUNNINGTON

Gender: Female
Correspondence Address:

PHOENIX, AZ 85072-2085

USA

Phone:
Alt. Phone:
Email:

CIRCLE K DELAWARE INC - Stockholder
Name: CIRCLE K CORPORATION
Contact Name: MARIA DANIELLE BURGESS
Type: CORPORATION
AZ CC File Number: State of Incorporation: AZ

Incorporation Date:
Correspondence Address:

PHOENIX, AZ 85072

USA
Alt. Phone:

Page 3 of 6

CIRCLE K STORES INC - Vice President

Name: EDILBERTO QUINTANA
Gender: Male
Correspondence Address:

PHOENIX, AZ 85072-2085

USA
Phone:
Alt. Phone:
Email:

MACS CONVENIENCE STORES INC - Stockholder

Name: COUCHE TARD INC
Contact Name: MARIA DANIELLE BURGESS
Type: CORPORATION
AZ CC File Number: State of Incorporation:
Incorporation Date:
Correspondence Address: P|

PHOENIX, AZ 85072

USA
Alt. Phone:
Email es

CIRCLE K STORES INC - Asst. Secretary

Name: MARIA DANIELLE BURGESS
Gender: Female

Correspondence Address:

PHOENIX, AZ 85072-2085

USA

Phone:
Alt. Phone:
Email:

CIRCLE K CORPORATION - Stockholder
Name: COUCHE TARD US INC
Contact Name: MARIA DANIELLE BURGESS
Type: CORPORATION
AZ CC File Number: State of Incorporation:

Incorporation Date:
Correspondence Address:

PHOENIX, AZ 85072

USA
Phone: Pe
Alt. Phone:

Page 4 of 6

COUCHE TARD US INC - Stockholder

Name: MACS CONVENIENCE STORES INC

Contact Name: MARIA DANIELLE BURGESS

Type: CORPORATION

AZ CC File Number: State of Incorporation:

Incorporation Date:

Correspondence —_ |

PHOENIX, AZ 85072

USA
Alt. Phone:
MANAGERS
Name: JANET KAY MEZA

Gender: Female

PHOENIX, AZ 85072-2085
USA

Phone:
Alt. Phone:
Email:

APPLICATION INFORMATION

Application Number: 394610
Application Type: Location Transfer
Created Date: 04/03/2026

QUESTIONS & ANSWERS

009 Liquor Store

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)
3,117 feet
Marionneaux Elementary School
24155 W Roeser Rd, Buckeye AZ 85326

Page 5 of 6

12) Are you one of the following? Please indicate below.

Property Tenant
Subtenant
Property Owner
Property Purchaser

Property Management Company

Property owner

13) Is there a penalty if lease is not fulfilled?

No

14) What is the total money borrowed for the business not including the lease?

Please list lenders/people owed money for the business.

N/A

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?
5/6/2027
DOCUMENTS
DOCUMENT TYPE FILE NAME UPLOADED DATE
ALIEN STATUS Scan_from_WARLM0304-03-2026- 04/03/2026
110850.pdf
ORGANIZATIONAL DOCUMENTS _ Scan_from_WARLM0304-03-2026- 04/03/2026
11091 1.pdf
QUESTIONNAIRE Scan_from_WARLM0304-03-2026- 04/03/2026
111003.pdf
QUESTIONNAIRE Scan_from_WARLM0304-03-2026- 04/03/2026
111020.pdf
DIAGRAM/FLOOR PLAN Scan_from_WARLM0304-03-2026- 04/03/2026
110924. pdf
QUESTIONNAIRE Scan_from_WARLM0304-03-2026- 04/03/2026
111100.pdf
QUESTIONNAIRE Scan_from_WARLM0304-03-2026- 04/03/2026
111114.pdf
MISCELLANEOUS Scan_from_WARLM0304-03-2026- 04/03/2026

113448.pdf

Page 6 of 6

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Arizona Department of Liquor Licenses and Control

https://www.azliquor.gov DLLC USE ONLY
(602) 542-5141 Job #: ZAW NO
Date Acpeptedt 3 “2b
Personal Information z =i
Questionnaire ———
OAOTOVSL

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. FP CULRANT \o\w\zu

Agent: a person who
is designated by an
applicant or licensee
to receive
communications from

SECTION - 1 INDIVIDUAL INFORMATION

the department and to MIAGENT MICcONTROLLING PERSON LC manacer

file and sign

documents submitted . .

tothe departmenton |] 1. Name: Burgess Maria Danielle

behalf of the applicant Last First Middle

or licensee. An agent 7 7 hz :

isnot'’s mally 2. Social Security #: Birth Date: Pe
(NOT a public record) (NOT a public record)

A.R.S. §4-202(A). 3. Driver’s License #: State Issued: AZ

(NOT a public record)
Controlling Person: |} 5. Are you a resident of Arizona? (yes Lo Date ofresidency: 01 /01_/ 1989

person directly or

indirect possessing | 6, Email address: Ai

control of an applicant

or licensee. 7. Home Address: iii
8. Daytime phone |) §$§xxaXxxaXaXnXxn Alternative phone #:

Manager: An
individual (not an
entity} appraved by SECTION 2 — LICENSED BUSINESS INFORMATION
the Department of
Liquor who has the
authority to organize, |! 1. License Number:
direct, carry out,
control or to
otherwise operate the
day-to-day operations
of a liquor-licensed 3. Business Address:
business.

A.R.S. §4-101(22) and

A.R.S. §4-202(C)

5/5/2025 Page 1 of 2 LIC-GEN-QUEST-001
Individuals requiring ADA accommodations please call (602)542-2999

09070182

2. Business Name (doing business as): Circle K Store #9615

23900 W Broadway Road Buckeye AZ 85326

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? Cohgent Lcontrolling Person [¥]Manager
Janet Meza

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

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 [YJ 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 [J
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) Maria Danielle Burgess 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.

va. 413 [2020

UC-GEN-QUEST-001

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

256, 4 1G Liar, Bert ait (46

a

Questionnaire Supplementary for AZ Dept of Liquor License & Control
Entity Responses - Circle K Stores Inc

QUESTION 1: Entity response for Circle K Stores Inc.
Circle K Stores Inc Interest in any other alcoholic beverage business:

Alimentation Couche-Tard Inc is a publicly traded company and has several
subsidiary's which operate approximately 10,200 retail convenience markets
in the United States, Canada, and Europe under the following names.

Circle K

Kangaroo Express
Mac's
Couche-Tard
Statoil

Ingo

Most of these sites have alcohol.
Circle K Stores Inc operates approximately 3,600 stores in 27 states.

Interest is limited to employee/officer relationship.

QUESTION 3: Entity response for Circle K Stores Inc.

License applications denied - It is the company's policy to secure alcohol
licenses prior to constructing/acquiring sites. If an agency recommends denial of a
license application for just cause (close to school, church, high crime area, etc), the
application is usually withdrawn and the site is not purchased.

Licenses suspended/fined - The company trains its employees on the techniques
of alcohol management. Periodically an employee of ours may incur a violation
related to alcohol. Some jurisdictions will only issue a citation to the employee,
therefore it is difficult to obtain knowledge of these violations. When the company
is also issued a citation, the company may be fined a dollar amount or the

store is required to suspend sales for a period of time. A report of citations can be
created by request for those citations where the company was fined.

Licenses revoked - To the best of our knowledge there has been no alcohol
license revoked.

Circle K Stores Inc operates approximately 3,600 stores in 27 states.

Interest is limited to employee/officer relationship.

Signature:

Maria Danielle Burgess - Agent/Assftant Secretary

| ar
WIM [LICENSENO.| STORE| City
“10074267_| 2872 | Phoenx | $3,000 00 1 312026 AZDOL Yes na__|Faiure to venty the legal ageSaie to ming Terminated
WaT [UIGENSENO | STORE| CITY AMT “ath | VDATE AGENCY | CUB | ASKID [VIOLATION [EMPLOYEE
BApe | 09070167 [3479 | Gita bend i 432025 AZDOL 7 na___[Faiure to request (O Termaat
WaT [LiCl EMPLOYEE
23-Aug| 9070215. 3405 Phoena 3250 00 i Bzae024 na na Fature ot folow mentifiachon procedures | Teermnated,
— - 2023 AZUGUORMOLATIONS 2023,
= Dismissed ist es ath tot = ‘
i o 4, a ee ° = =m)
—— — + . an 4. t — :
MTH [UICENSENO.| STORE| CITY AMT | tatand.amh] __V-DATE AGENCY | CUB | ASKiD [VIOLATION EMPLOVEE.
Fi 10070317_| 1795 | Phoens © 1 Wi202s “AZDOL na fa [Sale to Minor Alconot Terminated
25Jut 473 Grobe 0, 7 AZDOL 7 a ‘Sale to Inlowcated or Disorderly Person Tecnnated
| 26-0ct| 12 | 689 Globe 20. 1 5/15/2023 ‘AZOOL 7 na Sale to Intoxicated of Disorderly Parson Terminated
‘4Nov | 10074921 | 6647 | Phoenax NA 1 T1Mr2073 AZDOL m ‘na | Sale fo Minor - Aiconot Termasted
main TL “NO.] STORE EMPLOYEE.
Zo-may| 09070138 | 1950 ‘Terminated
["5-Oet | 09070140 [1908 Termnnted
MIM [UCENSENO.| STORET CITY aM tsi2nd.ath]| _ V-DATE AGENCY | CUB | ASKID [VIOLATION YEE
Zasut] 09070189 | 5024 | Phoenix 3159. 1 FERRO ‘AZDOU oo 7 ‘Sell, offer (9 $00, use rugs on premise iz
ss 2070 - = z 5 ==
‘ : Dismissed ———h : =
aes . ——} } - = —
TIM [UCENSENO| STORE| City BMY | istindath]V-DATE AGENCY | CUB | ASKID [VIOLATION EMPLOYEE

Page tof t

Arizona Department of Liquor Licenses and Control!

https://www.azliquor.gov DLLC USE ONLY
(602) 542-5141 fob ZOU ONO
] Date A fed:
FG 3-2L
ALIEN STATUS es)
Ucense #:
O9407 O\BL

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, 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 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 I — APPLICANT INFORMATION

Maria Danielle Burgess

APPLICANT NAME (Print ortype)

SECTION II — CITIZENSHIP OR NATIONAL STATUS

Are you a citizen or national of the United States? Yes oO No - If yes, indicate place of birth:
i United States of America
cry Clearwater stare F lOrida country

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

Arizona Drivers License

2) Nameof document:

If you answered No, you must complete Sections III.

LIC-GEN-ALIENSTAT-001

5/5/2025 Page 1of3
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.

9/5/2025

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 I-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.

. Atribal 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 2of3 LIC-GEN-ALIENSTAT-001
Individuals requiring ADA accommodations please call (602)542-2999

4 iO vig. beet 745

SECTION fll — QUALIFIED ALIEN

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))
Cianalien lawfully admitted for permanent residence under the Immigration and Nationality Act(INA)

[-)2.an alien who is granted asylum under Section 208 of the INA.

O 3.A refugee admitted to the United States under Section 207 of the INA.

4 analien paroled into the United States for at least one year under Section 212(d)(5) of theINA.
(1s.An alien whose deportation is being withheld under Section 243(h) of the INA.

Oo 6.An alien granted conditional entry under Section 203(a)}(7) of the INA as in effect prior to April 1, 1980.

oO 7.An alien who is a Cuban/Haitian entrant.

([] 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. A citizen 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 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 otherwise lawfully present in the United States.

PLEASE NOTE: The federal Personal Responsibility and Work Opportunity Reconciliation Act may make persons
who fall into this category ineligible for licensure. See 8 U.S.C. §

Maria Danielle Burgess Yd, /: 3/202 bo
Print Name Signature Date
5/5/2025 Page 3 of 3 LIC-GEN-ALIENSTAT-001

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

tg 4 40 Liv. Det AH ade
Arizona Department of Liquor Licenses and Control

https://www.azliquor.gov DLLC USE ONLY
(602) 542-5141 Hab OWN AD
Date Accepted: .
Personal Information on HO3- 2
Questionnaire Tani
OAOTO\BL

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. FP Covrent so0la\\21

Agent: a person who
is designated by an
applicant or licensee
to receive
communications from

SECTION - 1 INDIVIDUAL INFORMATION

the department and to CJAGENT [VICONTROLLING PERSON CJ manacer
file and sign

documents submitted . .

tothe departmenton |! 4. Name:.Quintana Edilberto

behalf of the applicant
or licensee. An agent
is not a manager.

First Middle

Last
2. Social Security A Birth Date:

a public record) {NOT a public record)
3. Driver's License ol State Issued: Arizona

{NOT a public record)

5. Are you a resident of Arizona? _[]Yes [No Date of residency: 08 04 72025

6. Email address: | CSC
7. Home Adress:
8. Daytime phone a. Alternative phone a.

Manager: An

individual (not an

entity) approved by SECTION 2 — LICENSED BUSINESS INFORMATION
the Department of
Liquor who has the
authority to organize, 1. License Number:
direct, carry out,
control or to
otherwise operate the
day-to-day operations
of a liquor-licensed 3. Business Address:

business.

A.R.S. §4-202(A).

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

A.RS, §4-101(10).

09070182

2. Business Name (doing business as): Circle K Store #9615

23900 W Broadway Road Buckeye AZ 85326

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

5/5/2025 Page 1 of 2 LIC-GEN-QUEST-001
Individuals requiring ADA accommodations please coll (602)542-2999

roe, & 40 Liar. bert A Fd

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.

om
@?
Who is managing the day to day operations? Chhgent EXtomrotting Person anager

Name of persons who will be handling the day to day operations: Janet Meza

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 [J
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) Edilberto Quintana hereby swear under penalty of perjury and in

compliance with A.R.S. § 4-210(
the information and state tL

Sve made herein are true and correct to the best of my knowledge.

Date: 4Z 2 026

Signature:

Page 2 of 2 UC-GEN-QUEST-001
Individuals requiting ADA accommodations please call (602}542-2999

5/5/2025

7G 4 i Liar. Bert a Fah

Questionnaire Supplementary for AZ Dept of Liquor License & Control
Entity Responses - Circle K Stores Inc

QUESTION 1: Entity response for Circle K Stores Inc.
Circle K Stores Inc Interest in any other alcoholic beverage business:

Alimentation Couche-Tard Inc is a publicly traded company and has several
subsidiary's which operate approximately 10,200 retail convenience markets
in the United States, Canada, and Europe under the following names.

Circle K

Kangaroo Express
Mac's
Couche-Tard
Statoil

Ingo

Most of these sites have alcohol.
Circle K Stores Inc operates approximately 3,600 stores in 27 states.

Interest is limited to employee/officer relationship.

QUESTION 3: Entity response for Circle K Stores Inc.

License applications denied - It is the company's policy to secure alcohol
licenses prior to constructing/acquiring sites. If an agency recommends denial of a
license application for just cause (close to school, church, high crime area, etc), the
application is usually withdrawn and the site is not purchased.

Licenses suspended/fined - The company trains its employees on the techniques
of alcohol management. Periodically an employee of ours may incur a violation
related to alcohol. Some jurisdictions will only issue a citation to the employee,
therefore it is difficult to obtain knowledge of these violations. When the company
is also issued a citation, the company may be fined a dollar amount or the

store is required to suspend sales for a period of time. A report of citations can be
created by request for those citations where the company was fined.

Licenses revoked - To the best of our knowledge there has been no alcohol
license revoked,

Circle K Stores Inc operates approximatély 3,600 stores in 27 states.

Signature: Z
yas YQuintaha - Vice President

/

MTH | LICENSE-NO.| STORE MPLOYEE
Sivan] 1o0reze7_| 2972 19 no Termnaied
a 2025 = —= =e
MIM | LIGENSENO.| STORE (iad AMT ‘stind..4th] _V-DATE AGENCY ‘cus _T _ASK4O [VIOLATION [EMPLOYEE
DApe | 09070167 3479 Gila bend $3,000.00 1 482025 AZDOL na na | Failure to request 0 Tormnated

EMI cE
n Termnated
a 2023 AZWQUOR WoLATIONS "2023 = a
il {Dismissed "iat 2 sea ah ru ~ ——__¢
3 = 8 a Sr oe ° 4 i =
* " —— . + oa © =z
MTH [LICENSENO.| STORE| CITY AMT [istind.aih] VDATE AGENCY | CUB | ASKAD [VIOLATION EMPLO’
i-Feb 10070357 1795 Proetun 1,500 00. 1 2 AZDOL. na na ‘Sale to Minor- Alcohol
25Jul | __ 0904009, 423 Globe 16.25 00 : 7232023 AZDOW na Sala to intowcated or Disorwenty Person
26-Oet] 0904012 620 Globe. 1,258 00 x 511572023 AZDOW a na ‘Sala to Intoxicated or Disorderty Person ferminated
“4éhov | 10074921 | 6847] Phoenoe NA 1 14472023 AZOOL 77 ha |Saie fo Minor. Alcohol ‘erm
_ . 2022 a
= Dismissed Ee —————
- —+ o - = - +
MTH [LICENSE.NO.| STORE CITY CUB [| _ASKID [VIOLATION [EMPLOYEE
| 09070138_}__1950_|__Phoanes_|} 20 1 $20'2022 ‘AZDOL na na__|Sale to Minor- Alcano! Termnated
‘Soc | ogo7oio [1908 | Giendaio '$1,500.00 1 i ‘AZDOW 38 fia [Sale to Minor Alcohol
+ — 8. O — -
+ { ae. a a - i
MIM [LIGENSENO.| STORE| CITY AMT __] tst,2nd..4th [VIOLATION [EMPLOYEE
ZSJui| oso701es | $024 | Phoenx $750.00 1 F262025 ‘AZDOL 1. or ‘Sail, offer 10 $86, uve Grogs on premise Terminated
i! “I Dismissed ist 2nd 5 —— L —
| o.oo. oO - — - t =
- 4 ai! —— 5
MIN [UCEN: STORE| _ciry, Ant | tetind.ath] _V-DATE AGENCY | CUB | ASKID [VIOLATION EMPLOYEE

Page t oft

#

a. tiny, pert ae Tid
Arizona Department of Liquor Licenses an :

ntrol

https://www.azliquor.gov DLLC USE ONLY
(602) 542-5141 Job# 2AW\O
Date Accepted:
Personal Information 7 a a
Questionnaire “ae
0407 O1S2

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. FP Curent Vol K|Ll

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

SECTION - 1 INDIVIDUAL INFORMATION

Cdacent [ZICONTROLLING PERSON (J MaNaGeR
1. Name: Cunnington (Kerr) Kathleen K
Last First Middle
2. Social Security iz Birth Date: aes
(NOT a public record)

INOT a public record)
3. Driver’s License , iff

(NOT a public record}

5. Are you a resident of Arizona? [Yes [No Date of residency: 05 _/01 _/ 2011

6. Email address inn
7.Home Address

State Issued: AZ

ar 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)

| 8. Daytime phone hil Alternative phone hil

SECTION 2 — LICENSED BUSINESS INFORMATION

1. License Number:.09070182

2. Business Name (doing business as): Circle K Store #9615

23900 W Broadway Road

Buckeye AZ 85326

3. Business Address:

5/5/2025

Page 1 of 2 LIC-GEN-QUEST-001

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