REDACTED PENDING JOB 349503_Redacted.pdf
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Received in the Buckeye City Clerk's office June 20, 2024 at 11:45 a.m. by LCA
State of Arizona
Department of Liquor Licenses and Control
Created 06/11/2025 @ 03:08:50 PM
Local Governing Body Report
LICENSE
Number: Type: 012 RESTAURANT
Name: HERITAGE @ OLD TOWN
State: Pending
Issue Date: Expiration Date:
Original Issue Date:
Location: 409 E MONROE AVENUE
BUCKEYE, AZ 85326
USA
Mailing Address:
Phone:
Alt. Phone:
Email:
AGENT
Name: KEVIN BARKO
Gender: Male
Correspondence Address: 409 EMONROE AVENUE
BUCKEYE, AZ 85326
USA
Alt. Phone:
OWNER
Name: HERITAGE @ OLD TOWN LLC 60th 8-10-25
Contact Name: KEVIN BARKO
Type: LIMITED LIABILITY COMPANY
AZ CC File Number: 23821086 State of Incorporation: AZ
Incorporation Date: 05/01/2025
Correspondence Address: Fo
BUCKEYE, AZ 85326
USA
Phone:
Alt. Phone:
Email:
Page | of 2
APPLICATION INFORMATION
Application Number: 349503
Application Type: New Application VV
Created Date: 06/02/2025
QUESTIONS & ANSWERS
012 Restaurant
1)
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
TENANT
Is there a penalty if lease is not fulfilled?
Yes
What is the penalty?
$265,140 -MAX
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.
0
Are there walk-up or drive-through windows on the premises?
No
Does the establishment have a patio?
Yes
Is the patio contiguous or non-contiguous (within 30 feet)?
CONTIGUOUS
Is your licensed premises now closed due to construction, renovation or redesign or rebuild?
Yes
If yes, what is your estimated completion date?
06/20/2025
What type of business will this license be used for?
RESTAURANT
Page 2 of 2
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RESTAURANT/HOTEL/MOTEL
OPERATION PLAN
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
Heritage @ Old Town
1. Name of restaurant (Please print):
2. Must indicate the equipment below by Make, Model, and Capacity:
LIST ONLY THE FOLLOWING - NO ATTACHMENTS
Imperial Tabletop-IRB-30 (15 Burgers)/Flat Top IMGA2428 (20 Large Pancakes)
Grill
Oven Conventional Imperial IR-6 (Accommodates full size 18x26 sheet pans)
Eraaser Kolpak Walk-In R10631 (302 Cubic Feet Storage)
Refrigerator Kolpak Walk-In R10631 (576 Cubic Feet Storage)
Sink Three (3) Sink Wash Station
Dish Washing Facilities Auto Chlor System A-4 (Can Wash 38 Racks per hour)
Food Preparation Counter .
(Dimensions) 10 feet x 30 inches
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?
, 100
(Do not include kitchen, bar, hi-top tables, or game area. %
5. Does your restaurant have a bar area that is distinct and separate from the dining area? Llyes No
(If yes, what percentage of the public floor space does this area cover?) Io
6. List the seating capacity for:
a) Restaurant dining area of your premises: [ 46 ]
(DO NOT INCLUDE PATIO SEATING) 0
b) Bar area [+o sds
tora, ,=46 ]
7/21/2022 Page 1 of 2
Individuals requiring ADA accommodations please call (602)542-2999
7. What type of dinnerware is primarily used in your restaurant? []Reusable | Disposable OC Both
8. Does your restaurant contain any games, televisions, or any other entertainment? Llyes No
Ifyes, specify what s and how many (examples: 4-IV's, 2-Pool Tables, 1-Video Game, etc.)
9. Do you have live entertainment or dancing? CQ YES No
Ifyes, 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 /Server
Hostesses
NM} NM] a] w
Managers
Servers
Other (PreP )
Dishwasher ) 2
Other (
Other (Busser j
1, (Print Full Name) Ashley Roberts 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 ers
Applicant Signature: / Z Et pe
| a
7/21/2022 Page 2 of 2
Individuals requiring ADA accommodations please call (602)542-2999
RECORDS REQUIRED
FOR AUDIT
RESTAURANT/HOTEL/MOTEL
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
In the event of an audif, 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:
Heritage @ Old Town
2. All invoices and receipts for the purchase of food and spirituous liquor for the licensed premises.
1.Name of restaurant (Please print):
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 (fo 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 fiquor 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
7/2/2022 Page 1 of 2
Individuals requiring ADA accommodations please call {602)542-2999
13. Payroll Records
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 work day)
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 which 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.RS. §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(G)
For the purpose of this section:
1. “Restaurant” means an establishment which derives at least forty percent (40%) of its gross revenue from the sale of food
2. “Gross revenue" means 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
under any other license that has been issued for the premises pursuant to this article.
1, (Print Full Name) Kevin Barko hereby swear under pen of perjury and in compliance
with A.R.S. § 4-210(A)(2) and (3) that | have read and understand the foregoing And verify }aat the information and
statements that | have made herein are true and correct to the best of my knoyi¢dge [a
Applicant Signature: 0
*MAKE A COPY OF THIS DOCUMENT AND KEEP IT WITH RECORDS REQUIRED BY THE STATE*
7/21/2022 Page 2 of 2
Individuals requiring ADA accommodations please call (602)542-2999
3 a ify GID i
SoS et) AEDLLC
HERYTAGE | BREAKFAST MENU
@ OLD TOWN eo,
Summer Edition - June 2025
GREAT FOOD, FRESH SERVICE
Serving Breakfast Seven Days a Week 6A-2P
Heritage Breakfast Deluxe Classic French Toast
Three eggs, bacon or sausage, seasoned Dour dough bread dipped in fresh egg with
potatoes, sour dough english muffin and pancake cinnamon, sugar and nutmeg. Served with
. $16.55 maple syrup and fresh strawberries. $12,85
Traditional Two Egg Breakfast Three Egg and Cheese Omelet
‘Two eggs, bacon or sausage, seasoned Build your own omelet with cheese, green
potatoes, sour dough English muffin. $13.50 pepper, sausage, bacon spinach, etc. $14.55
Huevos Rancheros Breakfast Platter AR Biscuits and Gravy
Rancheros - style breakfast-Mexican beef, Southern style biscuits and special AR recipe
refried beans,fried eggs, salsa, and cotija. gravy. $13.85
$16.90
English Muffin Breakfast Sandwich
Fresh sour dough english muffin with
scrampled eggs, sausage,and cheddar cheese.
$9.50
Onto.
SIDES HSC BEVERAGES SWEETS
Fresh Fruit Kabob Fresh Squeezed Juices Classic Cinnamon Roll
Fresh seasonal fruit. $6.50 $7.50 The tradition continiutes
Seasoned Potatoes Soda $6.95
Premium Idaho potatoes $2.75 Coke products 122 $2.55 Fresh Pastries
Sausage or Bacon Side Heritage Premium Coffee &Tea — Freshbaked wx of the day $7.50
Ahouse speciaty $3.50 Premium local roaster $2.25 Heritage Pastries
Fresh baked cake of the day $7.50
409 East Monroe Street
Buckeye . Arizona
Items may be served undercooked or contain raw ingredients. Consuming raw or uncooked
meats, seafood,shellfish or eggs may increase your risk for food borne illness.
725 JUN 2 antod0 AZDLLC
HERITAGE | LUNCH MENU
ee Summer Edition - June 2025
GREAT FOOD, FRESH SERVICE
Serving Lunch Seven Days a Week 11A-2P
Heritage Classic _— Caesar Salad
Chicken Salad Croissant a ietiueclietyericuome, Parton
Pi repair oe cheese with house made caesar dressing
fresh croissant. $15.85 $13.50 Add Chicken $4.50
Heritage Signature Burger Greek Salad
Our % pound “smash” burger is crafted from Mixed salad greens , tomatoes, cucumber, feta
home grown beef and grilled perfectly. $17.90 cheese, Kalamata olives, red onions and
Chicago's Rueben on Rye vinegarette dressing, $13.75
Chicago style Rueban with Vienna Corned Beef Marthas Vineyard Salad
pickled sauerkraut and topped with our
rueben sauce. $15.95 Mixed salad greens, fresh strawberries, and
tossed with house made vinegarette. $14.55
Ultimate Grilled Cheese
The Ultimate includes Montaray Jack, Smoked Our House Made Soup
Provolone, Cheddar on sour dough bread. JJune is Potatoe Chowder Month $3.25
$15.55
SIDES HSC BEVERAGES DESSERTS
Fresh Fruit Kabob Fresh Squeezed Juices Classic Cinnamon Roll
Fresh seasonal fruit. $6.50 $7.50 The tradition continiutes
French Fries Soda $6.95
Premium potatoe fries $2.75 Coke products 122 $2.55 Michigan Cherry Pie
Fresh Made Potatoe Chips Premium Coffee icyou
Ahouse speciaty $2.25 &Tea Heritage Lemon Cake
Premium local roaster $2.25 Fresh baked cake of the day $7.50
409 East Monroe Street
Buckeye . Arizona
Items may be served undercooked or contain raw ingredients. Consuming raw or uncooked
meats, seafood,shellfish or eggs may increase your risk for food borne illness.
Mo sires) GPTH |
ee aa HEP
HER|TAGE | COCKTAIL MENU
@ OLD TOWN
GREAT FOOD, FRESH SERVICE
Full bar avalable to mix your favorite cocktail
MIMOSA CLASSIC MOJITO
FRESH ORANAGE JUICE WITH FRESH ORANAGE JUICE WITH
A GLASS OF PROSECCO $12.50 A GLASS OF PROSECCO $13.70
Arizona Sunset Bloody Mary
Rum, OJ Passion fruit liquor $7.90 House made Mary Mix, Vodka,
Garden / Celery garnish. $12.50
Classic Margarita Tom Collins
Tequila, Triple Sec, Agave, Salted Gin, sweet/sour lime juiceand soda
rim and garnish $13.90 with tall garnish $13.90
DOMESTIC BEER $3.75 SPECIALTY BEER $4.75
Bud Light, Coors Light, Michelob Ultrat Kiltlighter and seasonal varieties
Arizona Vineyards
Ask your server for this weeks Arizona
Wine Special
o THE COFFEE BAR 4
Espresso . Americano.. Cappuccino .
Chai Tea $6.25
CHAI TEA, MILK & VANILLA
Japanesse Matcha Latte $6.25
Speciality Latttes $5.75
MOCHA, CINNAMOIN, NUTELLA
Two LeavesTea Flavors $2.25
DLLC USE ONLY
Arizona Dept. of Liquor Licenses and Contro!
https://www.azliquor.gov
(602) 542-5141
Fee:
me SHASO3
Date Accepted: 6-2-2>
CSR: DV
FP pending
905- A141
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).
. Social Security ii
N
. 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,
contro! or to
otherwise operate the
day-to-day operations
of a liquor-licensed
business.
A.R.S. §4-101(22) and
ARS. §4-202(C)
. Liquor License #:
. Business Name (doing business as):
. Business Address:
6/21/2024
SECTION - 1 INDIVIDUAL INFORMATION
LJAGENT MICONTROLLING PERSON CO Manacer
_ Name: Barko Kevin
Last First Middle
Birth Date:
OT a public record)
State Issued: Az
(NOT a public record)
. Are you a resident of Arizona? Yes CINo Date of residency: 02 p01 j2014
. Email aires
. Daytime phone A
Alternative phone iil
SECTION 2 — LICENSED BUSINESS INFORMATION
Heritage @ Old Town
409 E. Monroe, Buckeye, AZ 85326
Page 1 of 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.
Who is managing the day to day operations? Hagent [controlling Person CManager
Kevin Barko, Ashley Roberts
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 1 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 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 CJ 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 (J No
involved fraud or misrepresentation?
1, (Print Full Name) Kevin Barko 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 “ml nd statements that | have made herein are true and correct to the best of my knowledge.
_. May 29, 2025
Signature: Dat
6/21/24 Page 2 of 2
Individuals requiring ADA accommodations please call (602)542-2999
ALIEN STATUS
Arizona Dept. of Liquor Licenses and Control
800 W. Washington St. 5th 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 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 documeni(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
; Kevin Barko
APPLICANT NAME (Print ortype)
$$ — —
SECTION II — CITIZENSHIP OR NATIONAL STATUS DECLARATION |
Are you a citizen or national of the United States? Yes oO No - If yes, indicate place of birth:
cn Detroit Michigan United States
y te RY
Sta COUNT!
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 Il.
7/21/2022 Page 1 of 3
Individuals requiring ADA accommodations please call (602)542-2999
EVIDENCE OF U.S. CITIZENSHIP, U.S. NATIONAL STATUS, OR ALIEN STATU
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.
ll.
12.
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 coll (602)542-2999
SECTION III — QUALIFIED ALIEN DECLARATION
Applicants who are not citizens or nationals of the United Siates. Please indicate alien status by checking the
oppropriate 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 (lb) 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 theINA.
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.
HOOORADUO
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. Anonimmigrant 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 Wor portunity Reconciliation Act may make persons who fall
into this category ineligible for licensure. S: U.S.C.
Kevin Barko COV p May 29, 2025
Print Name \signature Date
7/21/2022 Page 3 of 3
Individuals requiring ADA accommodations please call (602}542-2999
FINGERPRINT VERIFICATION | pucusto™s
Arizona Department of Liquor Licenses and Control GSR: DNV
800 W. Washington St. 5" Floor Phoe AZ $5007
(602) 542-5141 FP nd
ace 6
Please follow the instructions below for fingerprinting this applicant
ATTENTION FINGERPRINT TECHNICIAN:
1. Please fill out or ensure that the applicant has filied out all the required boxes on the
fingerprint card prior fo taking the fingerprints.
i)
_ Request a valid, unexpired government-issued photo ID from the applicant and
compare the physical descriptors on the applicant's photo ID to the applicant and to
the information on the fingerprint card.
3. Fill out the information in the boxes below. Please print clearly.
4. Once the prints have been taken, place the fingerprint card and this form into the
envelope and sealit. Please write your name or identification across the edge of the seal.
Return the sealed envelope to the applicant.
Do not give the applicant the fingerprint card without first secling it inside fhe envelope.
5. Write applicants name on front of sealed envelope.
PRINT the following information:
| Date Name of Applicant: “|
|
|
6295 | _ Kevin 0. GacKo
Name of Fihgerprint Technician:
Fingerprint technician's Signatyte:
hnician’s Agency/company Name: | Phone Number:
Fingerprint t
Type of Photo rovided (check one):
Driver's License oO Passport 1 other (Please specify)
a _|
12/20/2022 Page 1 of 2
Individuals requiring ADA accommodations please call (602)542 2999
Arizona Department of Liquor Licenses and Control
800 W. Washington St. 5° Floor Phoenix, AZ 83007
(602) 542-514!
Your fingerprints will be used to check the criminal history records of the FBI.
If you have a criminal history record, the officials making a determination of your suitability for
employment, license, or other benefit must provide you the opportunity to complete or challenge
the accuracy of the information in the record. You should be afforded a reasonable amount of time
of twenty one( 21) days to correct or complete the record (or decline to do sv) before officials deny
you employment, license, or other benefit based on information in the criminal history record.
The procedures for obtaining a change, correction, or updating of your FBI criminal history
record are set forth in Title 28, Code of Federal Regulations, Sections 16.30 through 16.34.
Information on how to review and challenge your FBI criminal history record can be found at
www.fbi.gov under “Services” and then "Identity History Summary Checks" or by calling (304)
625-5590.
To obtain a copy of your Arizona criminal history in order to review/update/correct the record,
you can contact the Arizona Department of Public Safety Criminal History Records Unit at (602)
223-2222 to obtain a fingerprint card and a Review and Challenge packet. Information on the
review and challenge process can be found on the DPS website (www.azdps.gov).
Privacy Act Statement
This privacy act statement is located on the back of the FD-258 fingerprint card.
Authority: The FBI's acquisition, preservation, and exchange of fingerprints and associated information
Is generally authorized under 28 U.S.C. 534. Depending on the nature of your application,
supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential
Executive Orders, and federal regulations. Providing your fingerprints and associated information is
voluntary; however, failure to do so may affect completion or approval of your application.
Principal Purpose: Certain determinations, such as employment, licensing, and security clearances,
may be predicated on fingerprint-based background checks. Your fingerprints and associated
information/ biometrics may be provided to the employing, investigating, or otherwise responsible
agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI's
Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent
fingerprint repositories) or other available records of the employing, investigating, or otherwise
responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI
after the completion of this application and, while retained, your fingerprints, may continue to be
compared against other fingerprints submitied to, or retained by NGI.
Routine Uses: During the processing of this application and for as long thereafter as your
fingerprints and associated information/biometrics are retained in NGI, your information may be
disclosed pursuant to your consent, and may be disclosed without your consent as permitied by
the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the
Federal Register, including the Routine Uses for the NGI system and the FBI's Blanket Routine Uses.
Routirie uses include, but are not limited to, disclosures to: employing, governmental or authorized
non-governmental agencies responsible for employment, contracting, licensing, security
clearances, and other suitability determinations; local, state, tribal, or federal law enforcement
agencies; criminal justice agencies; and agencies responsible for national security or public safety.
As of 03/30/2018
12/20/2022 Page 2 of 2
Individuals requiring ADA accommodations please call (602)542-2999