Personal/Criminal History Statement (Gambling, Lottery, or Liquor licenses)
This form is required when applying for a Gambling, Lottery, Cigarette Wholesaler, Tobacco Products Distributor, or Liquor license.
Gambling, Lottery, Cigarette Wholesaler, and Tobacco Products Distributor licenses
A separate Personal/Criminal History Statement must be submitted by EACH of the following:
- Sole proprietor and spouse.
- Corporate officers.
- Partners and spouses.
- Limited partners who hold more than 10% interest in the business, and their spouses. (Spouses do not need to fill out the form for lottery license applications.)
- Financiers.
- Managers.
- Limited liability company members or managers and their spouses. (Spouses do not need to fill out the form for lottery license applications.)
- Stockholders that hold 10% of the issued stock.
Liquor license
Liquor Control Board will determine who must complete a Personal/Criminal History Statement. If you are applying for a liquor license and have any questions, please contact the Customer Service Division of the Liquor Control Board at (360) 664-1600.
Instructions
Please fill out the form completely and print it on white paper. Send the completed form with your license application to:
Master License Service
Department of Licensing
PO Box 9048
Olympia, WA 98507-9048
Fax: (360) 570-7875
Open the 
Personal/Criminal History Statement (For Liquor, Lottery, Gambling and Cigarette Wholesaler/Tobacco Distributor Licenses) form.
Please remember to enclose all necessary documents and fees with your completed application. Your license may be delayed if your application is incomplete. It is important that you contact our office, in writing, with any changes in address.
Questions?
For help filling out this form, please call us at (360) 664-1400.