Circle K #361679-Redacted Application.pdf

City of Buckeye — Regular Council Meeting (2025-11-18)

Extracted text (via ocr_local) 29240 characters

Received in the Buckeye City Clerk's office October 10, 2025 at 2:32 p.m. by LCA

State of Arizona
Department of Liquor Licenses and Control

Created 10/09/2025 @ 03:53:56 PM
Local Governing Body Report

LICENSE
Number: Type: 010 BEER AND WINE
STORE

Name: CIRCLE K STORE #9617
State: Pending
Issue Date: Expiration Date:
Original Issue Date:
Location: 19539 W INDIAN CSHOOL ROAD

BUCKEYE, AZ 85396

USA
Mailing Address:
Alt. Phone:

AGENT

Name: MARIA DANIELLE BURGESS
Gender: ° Female
Correspondence Address: Po

PHOENIX, AZ 85072-2085

USA
Phone:
Alt. Phone:
Email:

OWNER

Name: CIRCLE K STORES INC
Contact Name: MARIA DANIELLE BURGESS
Type: CORPORATION
AZ CC File Number: F00065980 State of Incorporation: AZ

Incorporation Date: 04/08/1957 Vy
Correspondence Address: (Gel _ \a Is ads

PHOENIX, AZ 85072-2085

USA
Alt. Phone:
Officers / Stockholders

Page | of 6

Name: Title: % Interest:

CIRCLE K DELAWARE INC Stockholder 100.00
MARIA DANIELLE BURGESS Asst. Secretary

KATHLEEN K CUNNINGTON President,Sec, Treas, Director

MORTEN MICHAEL JENSEN VP

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

SA.
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: |

PHOENIX, AZ 85072

USA
Alt. Phone:

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: a
Alt. Phone:

Page 2 of 6

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: Pe
Alt. Phone:

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:
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:

PHOENIX, AZ 85072

USA
Alt. Phone:

Page 3 of 6

CIRCLE K STORES INC - Asst. Secretary

Name: MARIA DANIELLE BURGESS
Gender: Female
Correspondence Address:

PHOENIX, AZ 85072-2085

USA
Alt. Phone:
Email: Cs
CIRCLE K STORES INC - VP
Name: MORTEN MICHAEL JENSEN
Gender: Male

Correspondence Address:

PHOENIX, AZ 85072-2085

USA

Alt. Phone:
Email: SC

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,

USA
Alt. Phone:
Email es

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 Address:

PHOENIX, AZ
USA
Alt. Phone:

Page 4 of 6

MANAGERS

Name: JANET KAY MEZA
Gender: Female

PHOENIX, AZ 85072-2085

Alt. Phone:

Email: a

APPLICATION INFORMATION

Application Number: 361679

Application Type: New Application
Created Date: 09/22/2025
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)
2,945 feet
Verrado High School
20050 N Indian School Rd, Buckeye AZ 85396
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.
N/A
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?
09/02/2027

Page 5 of 6

DOCUMENTS

DOCUMENT TYPE FILE NAME UPLOADED DATE

MISCELLANEOUS Scan_from_WARLM0409-22-2025- 09/22/2025
09185 1.pdf

ORGANIZATIONAL DOCUMENTS Officer List.pdf 09/22/2025

ORGANIZATIONAL DOCUMENTS __ Written Consent from the board of 09/22/2025
directors - Morten Jensen.pdf

DIAGRAM/FLOOR PLAN Scan_from_WARLM0409-22-2025- 09/22/2025
092139.pdf

ALIEN STATUS Scan_from_WARLM0409-17-2025- 09/22/2025
08143 1.pdf

QUESTIONNAIRE Scan_from_WARLM0409-22-2025- 09/22/2025
093359.pdf

QUESTIONNAIRE Scan_from_WARLM0409-22-2025- 09/22/2025
094351 .pdf

QUESTIONNAIRE Scan_from_WARLM0409-22-2025- 09/22/2025
094421 .pdf

QUESTIONNAIRE Scan_from_WARLM0409-22-2025- 09/22/2025

094451 .pdf

Page 6 of 6

AZ DOL
AZ DOL

Circle K Stores Inc.

Texas 6/8/51
Charter No. 0010697700
FIN# 74-1149540
OFFICE Namo BUSINESS ADDRESS
PresidenUTreasuranSecretary/Director Kathy Cunnington 1130 W Warner Rd, Tempe, AZ 65284
Assistant Secretary Daniele Burgess 1130 W Warmer Rd, Tempe, AZ 65284

Director

Business Address: 1130 W Warner Road, Bidg B. Tempe,AZ 85284 (602) 728-8000
Domicie Address: % CSC-Lawyers Incorporating Sernice Company. 701 Brazos Street, Sue 1050, Ausuin, TX 78701

12,000,000 Shares Authonzed, 1,000 issued at $100 Par 100% owned by Circle K Delaware Inc (FIN 46-0520672)

Circle K Stores Inc. is qualfied in:
AL, AZ, AR, CA. CO, FL, GA, , ID, KS, LA, MS,
MO, NV, NM, NC, OK, OR, SC, TN, TX. UT. WA

Corporate Structure:

Circle K Delaware Inc is 100% owned by The Circle K Corporation (Kathy Cunningion - PresidentiDuector)

The Circle K Corporation is 100% owned by Couche-Tard US Inc. (Kathy Cunnington - PresidenvDuector)

Couche-Tard US Inc. is 100% owned by Mac’s Convenience Stores Inc (Kathy Cunnington - PresidentDirector)

Mac’s Convenience Stores Inc |s 100% owned by Couche-Tard Inc. (Kaihy Cunnington - Sr. Vice President)

Couche-Tard Inc. is 100% owned by Depan-Escompte Couche-Tard inc (Kathy Cunnington - Sr. Vice President)
Depan-Escompte Couche-Tard Inc. is 100% owned by Alimentation Couche-Tard Inc. (Kathy Cunnington - Sr, Vice President)
Almentauon Couche-Tard inc Is a pubicly traded company (Kathy Cunnington - St. Vice President)

OFFICERS XLS

AZ OLLt
SEP 22 202

AZ DLLC
SEP 22 208

WRITTEN CONSENT OF
THE BOARD OF DIRECTORS OF
CIRCLE K STORES INC.

The undersigned, being all the directors of Circle K Stores Inc., a Texas Corporation
(the “Corporation’), in lieu of a meeting hereby consents to the following resolutions and the
actions contemplated therein, and directs that this written consent be inserted into the proceedings
of the Corporation:

SIGNING AUTHORITY OF MORTEN JENSEN

RESOLVED, Morten Jensen shall have the authority to sign on behalf of the
Corporation as its "Authorized Representative" any and all checks, drafts or other orders
for payment, all contracts, leases, licenses, deeds, mortgages and other agreements, and
all other certificates, instruments or other documents of any kind, in each case to the same
extent as though he were a duly authorized Vice President of the Corporation, unless
otherwise directed in a particular case by the sole Shareholder or as otherwise required by
any law applicable to the particular document in question.

This consent may be executed in counterparts, all of which shall be deemed to be part of one and
the same original instrument.

Dated as of September 30", 2021.

‘

KATHY CUNNINGTON DARRELL DAVIS

AZ DLLC
SEP 22 2025

WRITTEN CONSENT OF
THE BOARD OF DIRECTORS OF
CIRCLE K STORES INC.

The undersigned, being all the directors of Circle K Stores Inc., a Texas Corporation
(the “Corporation”), in lieu of a meeting hereby consents to the following resolutions and the
actions contemplated therein, and directs that this written consent be inserted into the proceedings
of the Corporation:

SIGNING AUTHORITY OF MORTEN JENSEN

RESOLVED, Morten Jensen shall have the authority to sign on behalf of the
Corporation as its “Authorized Representative" any and all checks, drafts or other orders
for payment, all contracts, leases, licenses, deeds, mortgages and other agreements, and
all other certificates, instruments or other documents of any kind, in each case to the same
extent as though he were a duly authorized Vice President of the Corporation, unless
otherwise directed in a particular case by the sole Shareholder or as otherwise required by
any law applicable to the particular document in question.

This consent may be executed in counterparts, all of which shall be deemed to be part of one and
the same original instrument.

Dated as of September 30", 2021.

KATHY CUNNINGTON DARRELL DAVIS

AZ DLLC
SEP 22 2025

iat 210
2

96eS8 ZV ‘eAexong
Py 1OOYNS UeIpU] AA GESEL soojovenes ge 1 N
LLOG# P1035 y| 810119 soit

Prey tt
StF
r=<aee5 pay

= yxgseouenug ——-—————--—--—— aegyeoueug

[e=sb—-------- a i 1) eal
Ta ale alee ¢ !

“Ey

Entrance/Exit

ox
r > me

c—"-9

fel

ee ee ee ee
| ri 1 T |

ne Unter ves nee toe Neen Ceenet Ones Cone

ae Cee Seen ee
BAes0js Jonbyy CI

ra
Besse
46 fect

Le 2 ¥2¥104),

Entrance/Exit

T_T 1 1 _1_}

DLLC USE ONLY.
Fee:

ci A\clb
Date cpa 99
cory Wa ; Qs/

fo Currey
lo- Wane

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

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 TH¥ ZINGHRERDT
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).

; i i
. Driver's License #°

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)

4/18/2023

. License Number:
. Business Name (doing business as

. Business Address:

SEP 22 2025
SECTION - 1 INDIVIDUAL INFORMATION
(acent [I cONTROLLING PERSON [ maNaAGER
_ Name: Burgess Maria Danielle
Last First Middle
. Social Security iz Birth Date:

{NOT a public record) (NOT a public recora)

State Issued: AZ —

(NOT a public record)

. Are you a resident of Arizona? Yes [INo Date of residency: Ot 701 71989 _

- Home Adress Ii
. Daytime phone iz

Alternative phone hit

SECTION 2 — LICENSED BUSINESS INFORMATION

new license

): Circle K Store #9617

19539 W Indian School Road, Buckeye AZ 85396

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

AZ DLLC
SECTION 3 — DAY TO DAY OPERATION OF BUSINESS SEP 22 2025

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? Clagent Ccontrolling 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 No O
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 O
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 (1 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 (1) No
involved fraud or misrepresentation?

|, (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.

sera) Yat I Wie Poueg Date: Ws leone

4/18/2023 Page 20f2
Individuals requiring ADA accommodations please call (602)542-2999

AZ DLLC

Questionnaire Supplementary for AZ Dept of Liquor License & Control SEP 2 2 2025
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 ofa
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: LO Dna A Rue

Maria Danielle Burgess - Agent/Ass&tant Secretary

AZ DLLC
SEP 22 2025

Page 1 of t

AZ DLLC
SEP 22 2025

ALIEN STATUS

Arizona Dept. of Liquor Licenses and Control
800 W. Washington St. 5!" Floor Phoenix, AZ 85007
(602) 542-5141

Type or Print with Black Ink

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 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 | — APPLICANT INFORMATION

Peer ee Maria Danielle Burgess

SECTION I! — CITIZENSHIP OR NATIONAL STATUS DECLARATION

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

cn, Clearwater siore FlOrida counry USA

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 Ill.

7/21/2022 Page 1 of 3
Individuals requiring ADA accommodations please call (602)542-2999

AZ DLLC

EVIDENCE OF U.S. CITIZENSHIP, U.S. NATIONAL STATUS, OR ALIEN STATUS
SEP 22 2025

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:

10.

Wile

13.

7/21/2022

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.

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 2 of 3
Individuals requiring ADA accommodations please Call (602)542-2999

AZ DLLC

—————
SECTION II! - QUALIFIED ALIEN DECLARATION SEP 22 2024

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)
2. An alien who is granted asylum under Section 208 of the INA.

3. Arefugee 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 the INA,

5. An alien whose deportation is being withheld under Section 243(h) of the INA.

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

. An alien who is a Cuban/Haitian entrant.

OOoodoogoouavn0

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 efseq.]:

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 thls category Ineligible for Ilcensure. See 8 U.S.C. §

Maria Danielle Burgess Fn Was. _ W1E[2025

—

Print Name Signature 4 Date

7121/2022 Page 3of3
Individuals requiring ADA accommodations please call (602)542-2999

AZ DLLC

Arizona Dept. of Liquor Licenses and Control DLLC USE ONLY

https://www.azliquor.gov Fea:
(602) 542-5141 RG sl
. Date peesRed cs
Personal Information ae a
Questionnaire APSor AV
0 Current
10 20-94)

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. AZ DLLC

Last
. Social Security a

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).

Manager: An
individual (not an
entity) approved by
the Department of
Liquor who has the
authority to organize,
direct, carry out,
control ar 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)

4/18/2023

blic record)
. Driver's License #;

. Are you a resident of Arizona? Yes DINo

. Daytime phone a. Alternative phone a ___|

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

. Business Address:

SEP 22 2025
SECTION - 1 INDIVIDUAL INFORMATION
Cacent LIcONTROLLING PERSON C MaNaGER
. Name: Jensen Morten Michael
First

Birth Date:

(NOT a public record)

State Issued: AZ

(NOT a public record)

Date of residency: 08 0172021

SECTION 2 — LICENSED BUSINESS INFORMATION

New License

cle K Store #9617

19539 W Indian School Road, Buckeye AZ 85396

Page lof 2
Individuals requiring ADA accommodations please call (602)542-2999

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. AZ DLLC

Who is managing the day to day operations? LJAgent Ccontrolling Person [Manager SEP 2 2 2025
Janet Meza

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

SECTION 4 —- BACKGROUND

1. Have you owned, or been a controlling person of any entities that held a liquor Yes No 0
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 1 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 1 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 L) No
involved fraud or misrepresentation?

1, (Print Full Name) Morten Michael Jensen 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’ its that bie heyéin are true and correct to the best of my knowledge.

Signature:

owe N50
WA f*

4/18/2023 Page 20/2
Individuals requiring ADA accommodations please call {602)542-2999