JOB #374614 REDACTED- Pita Kitchen.pdf

Received in the Buckeye City Clerk's office December 18, 2024 at 8:22 a.m. by LCA

State of Arizona
Department of Liquor Licenses and Control

Created 12/17/2025 @ 04:48:07 PM
Local Governing Body Report

LICENSE

Number: Type: 012 RESTAURANT
Name: PITA KITCHEN
State: Pending
Issue Date: Expiration Date:
Original Issue Date:
Location: 860 N VERRADO WAY

#104

BUCKEYE, AZ 85326

USA

Mailing Address:

BUCKEYE, AZ 85326

USA
Alt. Phone:
AGENT
Name: REIMUN SABRI SHLEIMUN
Gender:

Correspondence Address:

]
2.
@

BUCKEYE, AZ 85326

USA
Alt. Phone:
Email: es
OWNER

Page 1 of 3

Name: RIAN & RAY VERRADO LLC

Contact Name: REIMUN SABRI SHLEIMUN

Type: LIMITED LIABILITY COMPANY

AZ CC File Number: 23621143 State of Incorporation: AZ
Incorporation Date: 12/22/2023

Correspondence Address:

BUCKEYE, AZ 85326

USA
Alt. Phone:
Email: es
Officers / Stockholders
Name: Title: % Interest:
RIAN KORGIS HANNA Member 50.00
REIMUN SABRI SHLEIMUN Member 50.00
RIAN & RAY VERRADO LLC - Member
Name: REIMUN SABRI SHLEIMUN
Gender: Male

Correspondence Address: |

BUCKEYE, AZ 85326

USA
Alt. Phone:
Ema: es
RIAN & RAY VERRADO LLC - Member
Name: RIAN KORGIS HANNA
Gender: Male

Correspondence Address:

BUCKEYE, AZ 85326

USA
Alt. Phone:
Email: es

Page 2 of 3

APPLICATION INFORMATION

Application Number: 374614

Application Type: New Application
Created Date: 12/12/2025
QUESTIONS & ANSWERS

012 Restaurant

))

2)

3)

4)

5)

6)
7)

8)

9)

Are you applying for an Interim Permit (INP)?
No
Are you one of the following? Please indicate below.
Property Tenant
Subtenant
Property Owner
Property Purchaser
Property Management Company
PROPERTY TENANT
Is there a penalty if lease is not fulfilled?
Yes
What is the penalty?
10YEAR LWASE, $800K +
Is the Business located within the incorporated limits of the city or town of which it is located?
Yes
What is the total money borrowed for the business not including the lease?
Please list each amount owed to lenders/individuals.
NONE
Are there walk-up or drive-through windows on the premises?
No
Does the establishment have a patio?
No
Is your licensed premises now closed due to construction, renovation or redesign or rebuild?
Yes
If yes, what is your estimated completion date?
01/01/2026
What type of business will this license be used for?
RESTAURANT

Page 3 of 3

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Dishwasher

TTMEY ShOT we eT JS0S:

Arizona Department of Liquor Licenses and Control SHTEC Te anid AZDLLC

https://www.azliquor.gov DLLC USE ONLY
(602) 542-5141 Pe ZI IY
= = = Date Accepted: sag
RESTAURANT OPERATION PLAN | fd has C25
RESTAURANT SERIES 12 AND a
HOTEL/MOTEL SERIES 11 ONLY ;

Pita Kitchen

1. Name of restaurant (Please print):

2. Must indicate the equipment below by Make, Model, and Capacity:

LIST ONLY THE FOLLOWING - NO ATTACHMENTS

Grill ATOSA BROILER ATTG-36 36”

Oven NAT Now

Freezer 2X 2 DOOR FREEZERS ATOSA 44 CUB FT MBF8503GR, 1 DOOR FREEZER 19.1 CUB FT ATOSA MBF8501GRL
Refrigerator WALK IN COOLER 8X8 400 CUB FT, 2X MEGA TOP 134 CUB FT MSF8308GR, FRIDGE UCA4S 19.9CUB FT, 58° Atcsa Keg 17.3 CuFt WKCSEGR

Sink 1 PREP 24X24, 3 HAND SINKS, 1 X 3 COMPARTMENRT SINK

Dish Washing Facilities. | ADS AF/AFC-ES SERIES, 37 RACKS PER HOUR
Food Preparation Counter 2 TABLES 5’X3’

(Dimensions)

Other

3. Attach a copy of your FULL menu with pricing INCLUDING NON-ALCOHOLIC BEVERAGES

4. What percentage of your public premises is used primarily for restaurant dining?

(Do not include kitchen, bar, hi-top tables, or game area.) 28 %

5. Does your restaurant have a bar area that is distinct and separate from the dining area? Loves No

(If yes, what percentage of the public floor space does this area cover?) %
6. List the seating capacity for:

44
a) Restaurant dining area of your premises: [ ]
(DO NOT INCLUDE PATIO SEATING) 0
b) Bar area [ + ]
TOTAL [= 44 ]
5/5/2025 Page 1 of 2 LIC-APPREG-RESTOP-001

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

*SOLEL LORHIOdS AZOLLE
7. What type of dinnerware is primarily used in your restaurant? (reusable [¥]bisposable [Both

8. Does your restaurant contain any games, televisions, or any other entertainment? Lives No

If yes, specify what types and how many (examples: 4-TV’s, 2-Pool Tables, 1-Video Game, etc.)

9. Do you have live entertainment or dancing? Lyes No
If yes, what type and how often (example: DJ-2 x a week, Karaoke-2 x a month, Live Band-1 x a month, etc.)

10. List number of employees for each position:

Position How many

Cooks

Bartenders

Hostesses

Managers

Servers
other(CASHIER

Other ( PREP )

-~j;-?/O/-3-/;/O/;/0O/;A

Other ( )

I, (Print Full Name) Reimun Sabri Shleimun , 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 I have made herein are true and correct to the best of my pee oe
Applicant Signature:
PP iB / iS

LIC-APPREQ-RESTOP-001

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

CHEF NGPIRED

Lomb Chops Bowl $20 Lomb Chops Plate 2 $21
Protein Fries Bowl $7 PK Gyros EggRolls;...$10.5 “7

Family Meal (Feeds 3-5 People) ....
Includes Choice of § Proteins, Family Sized Rice, Choice o!
Souce, and Pita Breads!

BEVERAGES

Fountain Drink ....... $3.35 BottledBeer....... $5.5
Bottled Water $2.5

(Aveileble in come loestions)

Bottled Beveroges ..;. $3.75 Wine - ~ AVONDALE ~~ ARROWHEAD

9915.W McDowell Rd 20221 N 67th Ave
Avondale, AZ 85392 Glendale, AZ 85308
(623) 478-8900 ) (623) 476-7101

ai . : Download a
fal supe = Our Menu: - SURPRISE VERRADO

16853 N 145th Ave 1-10 and Verrado Way
ras Surprise, AZ 85374 Verrado, AZ
(623) 254-7050 COMING SOON

Choice of Fries or Rice
& Kid's Drink

Kid's Bow! Pitadilla

Chicken Showorma or Gyros Cheese, Chicken Shawarma or Gyros Le) Gaol
‘ EJ Our menu prices are based
"5 - on cash payments.
Chicken Nuggets Ciedit cord tronsai

(om WRAPS Sti}

Gyros
Chicken Shawarma.

Traditional or

Protein, Lettuce*, Tomatoes,
Red Onions &SOUCE (oyrosexcies iemice)

_Mediterranecn
Protein, Tomatoes, Sumac Onions,
Pickles & Toum Garlic Souce®

Greek

Protein, Hummus, Lettuce, Tomatoes
Red Onions, Feta Cheese
Mediterranean Pickles,

& Tzatziki Sauce

Extra Sauce + $0.75

Choose Your
Falafels Protein
Steak Shawarma... +15

—

Harvest Grill
Protein, Mix Grilled Veggies,
Lettuce & Tzatziki Sauce

Chipotle BLT
Protein, Smoked Bacon
Lettuce, Tomatoes, Grilled Onions

~ Q Chipotle Sauce

Extra Meat + $2.85

Pickles + $1.95 / Avocodos + $2.95 / Feta Cheese +$1.95

Side Solod (choiceotSelod) $6 +
Boklova (Piece) .... $4.

Hummus ....... $75 /$10.5

Bobo Ghonowsh $7.5 / $10.5
Vegetable Medley .:.. $6.5
Folofels (2 Pieces) ..... $3

(BOWLS /SALADS S16)

Choose Your
Gyros Folafels Protein
Chicken Shawarma Chicken Kobobs....... +§2
Steak Shawarma..... +925
Salmon .............. +$3 . Steak Kabobs

Choose ] Bose
Rice or Hummus
Protein, Sumoc Onions, Chopped
Cucumber & Tomato Salad &
Mediterroneon Pickles Coesor Solad
1 Protein, Romaine Lettuce, Roosted
Harvest Grill P . Chickpeos, Parmesan, Croutons
Protein, Italian Squash, Red Onions, 2 Coesar tiessing
Carrots, Red and Yellow Bell Peppers ~ (Without Protein il 3)
os well os Green Beans. All Sautéed eo
ond Seasoned To Perfection PK Fottoush Solod
{Without Protein $1175) Protein, Romaine Lettuce, Tomatoes,
s Red Onions, Cuicumbers, Sliced
-_— ~ {attuce: Teena Raddishes, Pomegranate Arils, Fried
in, Romaine eure, fomavoes, sumac Pita Chips & Our Homemade

Red Onions, Cucumbers, Feta Cheese, Shollot Pomegranate Vinoigrete
Pitted Block Kalamata Olivés, = eau

Peperoncini & Our Homemade (without Prtein 178)

Greek Dressing
(Without Protein $11.75)

Beets & Gout Cheese Salad +92 :,
Protein, Baby Arugilo, Sliced Beets,
Goot Cheese, Red Onions, Sliced

Apples, Tousted Walnuts & Balsamic
Vinoigrette (Without Protein $13.75)

(PLATES 517

--Falofels eect

Gyros

Chicken Shawarma —=—=—«Chicken Kabobs........ +82
Steak Shawarma..... +$25  BeefKobobs .......... +$2
Salmon

Rice Salad (choice tf Soiad)
Lentil Soup ;

Vegetable Medley woe 515

ScoopofHummus+ $1.75 Additional Bose + $2.75

Falafel (iPiece) +$1.5 / Avocados +$2.35 / Extra Meot+$2.85

(VEGETARIAN SAMPLER S1/}

Served with Hummus | Bobo Ghonoush | Folofels | Choice of Sold

Pitas/Wraps S11

Choose Your Protein
Gyros Falafels
Chicken Shawarma Steak Shawarma + $1.5
Traditional

Protein, Lettuce*, Tomatoes, Red Onions & SOUCE 2. ase tenee)
Mediterranean Harvest Grill
Protein, Tomatoes, Sumac Onions, Protein, Mix Gritted Veggies,
Pickles & Tourn Garlic Sauce Lettuce & Souce
Greek Chipotle BLT |
Protein, Hummus, Lettuce, Tomatoes Proten, Smoked Bacon
Red Onions, Feta Cheese Lettuce, Tomatoes, Grilled Onions
Mediterranean Pickles, & Taziki Souce & Chipotle Ranch Sauce

Extra Sauce + $0.75 Extra Meat + $2.85
Pickles + $1.25 | Avocados + $1.5 / Feta Cheese + $1.25

Sides |

Fries $4.5 Side Salad $6 (Greek or Ceasar)
Pita Chips & Hummus $4.5 Hummus $7.5 / $10.5
Lentil Soup $5 Baba Ghanoush $7.5/ $105
PK Greek Fries $5.5 Vegetable Medley $6.5
Baklava (1 Piece) $4.5 Falafels (2 Pieces) $3

Bowls/Salads $16

Choose Your Protein

Gyros Chicken Kabobs + $2
Chicken Shawarma Beef Kabobs + $2
Falafels Steak Shawarma + $2.5

Choose Your Base

Rice or Hummus
Protein, Sumac Onions, Chopped Cucumber & Tomato Salad &
Mediterranean Pickles

Harvest Grill

Protein, Italian Squash, Red Onions, Carrots, Red ond Yellow Bell Peppers as weil
as Green Beans. A Sautéed and Seasoned To Perfection

(Without Protein $11.75)

Greek Salad

Protein, Romaine Lettuce, Tomatoes, Red Onions, Cucumbers, Feta Cheese,
Pitted Block Kalamata Olives, Pepperchine & Our Homemade Greek Dressing
(Without Protein $11.75)

Ceasar Salad
Protein, ine Lettuce,
& Ceasar Dressing
(Without Protein $11.75)

Chickpeas, . Croutons

Pita Kitchen Salad
Protein, Spring Mix, Cherry

Plates $17

Choose Your Protein

Gyros Chicken Kabobs + $2
Chicken Shawarma Beef Kabobs + $2
Falafels Steak Shawarma + $2.5
Rice Salad (Greek or Ceasor)
Hummus Lentil Soup

Greek Fries + $1.5 Vegetable Medley + $1.5

Scoop of Hummus + $1.75 Add Avocados + $1.5
Falafel (1 Piece) + $1.5 Additional Base + $2.75
Extra Meat + $2.85

Red Onions, Ci Steed

Pomegranate Arils, Fried Pto Chips & Our Homemade Pomegronote Vinegrette
(Without Protein $11.75)

| Chef Inspired

Salmon Plate $20

Salmon Bowl $19
Steak Kababs Bowl $19 Steak Kababs Plate $20
Lamb Chops Bowl $20 — Lamb Chops Plate $21

Protein Fries Bowl $17. PK Gyros Egg Rolls $10.5

Vegetarian Sampler $17
Served with Hummus | Baba Ghanoush | Folafel & Selad (Greek or Ceasar)

Beverages
Fountain Drink $3 Beer $5.5
Bottled Water $2.5 Wine - Price Varies

Bottled Beverages $3.75

Kids Meals $7.75

Choice of Fries or Rice & Kid's Drink
Kid’s Bowl Pitadilla
Chicken Showerma or Gyros Cheese, Chicken Shawarma or Gyros
Chicken Nuggets

ivf

295 PEC eanto4 AZDLLC

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

(602) 542-5141 Job: S714 14
——— TE Pe28

RECORDS REQUIRED FOR AUDIT Lc: ae :

License #:

RESTAURANT/HOTEL/MOTEL

In the event of an audit, you will be asked to provide to the Department any documents necessary to determine
Compliance with A.R.S. §4-205.02(G). Such documents requested may include however, are not limited to:

; Pita Kitchen
1.Name of restaurant (Please print):

2. All invoices and receipts for the purchase of food and spirituous liquor for the licensed premises.

3. A list of all food and liquor vendors

4. The restaurant menu used during the audit period

5. A price list for alcoholic beverages during the audit period

6. Mark-up figures on food and alcoholic products during the audit period

7. Arecent, accurate inventory of food and liquor (taken within two weeks of the Audit Interview Appointment)
8. Monthly Inventory Figures - beginning and ending figures for food and liquor

9. Chart of accounts (copy)

10. Financial Statements-Income Statements-Balance Sheets

11. General Ledger

A. Sales Journals/Monthly Sales Schedules
1) Daily sales Reports (to include the name of each waitress/waiter, bartender, etc. with sales for that day)
2) Daily Cash Register Tapes - Journal Tapes and Z-tapes
3) Dated Guest Checks
4) Coupons/Specials/Discounts
5) Any other evidence to support income from food and liquor sales

B. Cash Receipts/Disbursement Journals

1) Daily Bank Deposit Slips
2) Bank Statements and canceled checks

12. Tax Records

A. Transaction Privilege Sales, Use and Severance Tax Return (copies)
B. Income Tax Return - city, state and federal (copies)

C. Any supporting books, records, schedules or documents used in preparation of tax returns

9/5/2025 Page 1 of2 LIC-APPREG-AUDITRCDS-001
Individuals requiring ADA accommodations please call (602)542-2999

13. Payroll Records 225 DEC Le aa1045 AZDLLC

A. Copies of all reports required by the State and Federal Government
B. Employee Log (A.R.S. §4-119)
C. Employee time cards (actual document used to sign in and out each workday)

D. Payroll records for all employees showing hours worked each week and hourly wages

14. Off-site Catering Records (must be complete and separate from restaurant records)

A. All documents that support the income derived from the sale of food off the license premises.
B. All documents which support purchases made for food to be sold off the licensed premises.

C. All coupons/specials/discounts

The sophistication of record keeping varies from establishment to establishment. Regardless of each licensee’s accounting
methods, the amount of gross revenue derived from the sale of food and liquor must be substantially documented.

REVOCATION OF YOUR LIQUOR LICENSE MAY OCCUR IF YOU FAIL TO COMPLY WITH
A.R.S. §4-210(A)7 AND A.R.S. §4-205.02(G).

A.R.S. §4-210(A) 7

The licensee fails to keep for two years and make available to the department upon reasonable request all invoices,
records, bills or other papers and documents relating to the purchase, sale and delivery of spirituous liquors and, in
the case of a restaurant or hotel-motel licensee, all invoices, records, bills or other papers and documents relating to
the purchase, sale and delivery of food.

A.R.S. §4-205.02(M)
For the purpose of this section:

Restaurant: an establishment that derives at least forty percent (40%) of its gross revenue from the sale of food
Gross revenue: the revenue derived from all sales of food and spirituous liquor on the licensed premises regardless of

whether the sales of spirituous liquor are made under a restaurant license issued pursuant to this section or under any
other license that has been issued for the premises pursuant to this article.

Declaration:
1, (Print Name) Reimun Sabri Shleimun , declare under penalty of perjury that | am

authorized to submit this application. | have read the contents and to the best of, wledge believe all statements
made on this application to be true, correct, and complete.

Signature:

*MAKE A COPY OF THIS DOCUMENT AND KEEP IT WITH RECORDS REQUIRED BY THE STATE*

5/5/2025 Page 2 of 2 LIC-APPREQ-AUDITRCDS-001
Individuals requiring ADA accommodations please call {602)542-2999

. . . AS DEC 120410:46 AFDLLC
Arizona Department of Liquor Licenses and Control
https://www.azliquor.gov

(602) 542-5144

DLLC USE ONLY

et 2714 lol Y
TATE D025
Lc: s (Cs

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.

. Name:

Last First
. Social Security —_ £4 Birth Date:
‘ff public record)
. Driver’s License #:

. Are you a resident of Arizona? Yes LNo

. Email address:

Home Address: i
. Daytime phone #: LC tl Alternative phone #:

|| 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)

. License Number:

. Business Name (doing business as): Pisa a Ache vas
. Business Address: Hoo N 2 U eyvado

5/5/2025

511%

SECTION - 1 INDIVIDUAL INFORMATION

[MANAGER

MaGent

[IcONTROLLING PERSON

Reimun Sabri
Middle

Shleimun

(NOT a public record)
State Issued: AZ

(NOT a public record)

Date of residency: 02 701 72002

SECTION 2 — LICENSED BUSINESS INFORMATION

Wad}, Ay
Az $8326

Puckeye

Page 1 of 2 UC-GEN-QUEST-001

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

SECTION 3 — DAY TO DAY OPERATION OF BUSINESS "PO DEC 12 A106 AFD

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? ncont controlling Person (Manager

Reimun Shieimun
Name of persons who will be handling the day to day operations: ee Shlomi

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

Reimun Sabri Shleimun
I, (Print Full Name) 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 state: | have made herein are true and correct to the best of my knowledge.

_ 12/11/2025

Signature: f Date

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

"eo DEC 12 AH10:46 AZDLL

REIMUN SHLEIMUN

December 10, 2025
Arizona Department of Liquor

To Whom it May Concern,

Reimun Shleimun has been a controlling agent for Rian & Ray, LLC DBA Pita Kitchen since
2013. With License Numbe It's in good standing and active. Business is

located at i Avondale AZ 85392.

Sincerely yours,

cll \alias

REIMUN SHLEIMUN Date

20489 N 79th Ave Peoria AZ 85382 United States 123-456-7890 www.example.com

"PSLEC 12 Ant AZDLLC

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

(602) 542-5141 S714 14
TET 205

—— = License #:

ALIEN STATUS

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 |, Il, 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

Reimun Sabri Shleimun

APPLICANT NAME (Print ortype)

Are you a citizen or national of the United States? Yes O No - If yes, indicate place of birth:
Zakho Dohuk Iraq

City State COUNTRY

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

2) Nameof document: Ae Oxwers hcanse

If you answered No, you must complete Sections |II.

5/5/2025 Page 1 of 3 UC-GEN-ALIENSTAT-001
Individuals requiring ADA accommodations please call (602)542-2999

725 DEC 12 aNiOd6 AZDLLC
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:

iP

11.

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 UnitedStates.

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.

A tribal certificate of Indian blood.

. Atribal 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 2 of 3 LIC-GEN-ALIENSTAT-001
Individuals requiring ADA accommodations please call (602)542-2999

| SECTION Ill — QUALIFIED ALIEN 4 ASO |

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))
O 1.An alien lawfully admitted for permanent residence under the Immigration and Nationality Act (INA)
O 2.An alien who is granted asylum under Section 208 of the INA.
oO 3.A refugee admitted to the United States under Section 207 of the INA.
my An alien paroled into the United States for at least one year under Section 212(d)(5) of theINA.
| 5.An alien whose deportation is being withheld under Section 243(h) of the INA.
(Ce.analien 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.

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. 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 licensuse- 8 U.S.C. §

Reimun Sabri Shieimun ' ee 12/11/2025

a

Print Name Signature Date

5/5/2025 Page 3 of 3 LIC-GEN-ALIENSTAT-001
Individuals requiring ADA accommodations please call (602)542-2999

C128n1046 AZDLLC
mal Pa ID Number: 2ff2593b-e1a2-42e7-b782-997177425613 O On-sale
t O Off-sale

Certificate of Completion EJ _On- and off-sale
For
Title 4 BASIC Liquor Law Training

A Certificate of Completion must be on a form provided by the Arizona Department of Liquor. Certificares are completed by a state-
approved training provider and, when issued, the Certificate is signed by the course participant.

The State requires BASIC Title 4 training only as a perequisite for MANAGEMENT Title 4 trainign or as a result of a liquor law violation. Persons
required to have BASIC Title 4 training are listed at the base of this Certificate. Licensees sometimes require BASIC Title 4 Training a condition of

employment.
Areplacement Certificate of Completion for Title 4 training must be available through the training provider for two years after the training
completion date.

Student Information
Seimun Sabe-Shleimun

WC ee se , oa Se,

Signature

olds /2025 07/01/2028

Training Completion Date Certificate Expiration Date
(three years from completion date)

Training Provider Information
ABC - Arizona Business Council for Alcohol Education

Company Name

8155 North 24th Avenue, Suite A; Phoenix, AZ 85021

Mailing Address

(602) 285-1396

Daytime Contact Phone Number

L Jerry Jacobsen _ certify that the above named individual did successfully complete
Instructor Name (please print)

Title 4 BASIC Training in accordance with A.R.S. §4-112(G) (2) and Arizona Administrative Code(A.A.C.)R19-1-103

using training course content and materials approved by the Arizona Department of Liquor Licenses and Control.

| understand that misuse of this Certificate of Completion can result in the revocation of State-approval for the Title

4 Training Provider named in thjssection as provided by A.A.C. R19-1-103(E) and (F).
an @ 01/07 2025

aw) “siructor Signature Day Mo Year
i

Persons required to Compiet® BASIC & MANAGEMENT Title 4 Training: 1) owner(s) actively involved in the daily business operations of a liquor-
licensed business of a series listed below

2) licensees, agents and managers actively involved in the daily business
operations of a liquor-licensed business of a series listed below

Government (series 5) Bar (series 6) Beer & Wine Bar (series 7}
Liquor Store (series 9) Private Club (series 14) Hotel/Motel w/restaurant (series 11)
Beer & Wine Store (series 10)

In-state Microbrewery (series 3)
Conveyance (series 8)
Restaurant (series 12) In-state Farm Winery (series 13)

Liquor license applications {initial and renewal) are not complete until valid Certificates of Completion for all required persons have been
submitted to the Department of Liquor.

The questionnaire (which designates a manager to a location) and the agent change form (which assigns a new agent to active liquor
licenses) are not complete until valid Certificates of Completion for all required persons have been submitted to the Department of Liquor.

July 11, 2013 ABCA-103 REV. 8/16