ALCOHOLIC BEVERAGE CONTROL (ABC) LICENSE RENEWAL ISTRUCTIONSYour license may be re-issued the same day or it may be forwarded to the ABC Board for review. FEES APPLICATIONapplication designates the person in whose name the license will be issued if the application is approved. An applicant that wants to designate another individual to pick up the license must submit a written authorization to ABRA. An applicant must be at least 21 years of age and provide a valid government issued form of identification. Applications with ABRA must be submitted in person at: 2000 14th St., NW, 4th Floor, Suite 400 South, Washington, DC 20009Office Hours: 8:30 a.m.-4:00 p.m., Monday-Friday OTHER FORMS REQUIRED Personal Information Release AuthorizationClean Hands CertificationCourt DispositionAlcohol Awareness Certificate American LegalNet, Inc. www.FormsWorkFlow.com RENEWAL APPLICATION Fees Paid: $ Date Accepted: Accepted by: License Period: From To Issue Date: TO BE COMPLETED BY APPLICANT 1.License Number 2e (Last, First, Middle Initial) 3.Date of Birth 4.Place of Birth 5.Personal Telephone Number 6.Residential Address City State Zip Code 7.Email ddress 8.re you eligible to work in the United States? Yes No d. Work PermitVisa a. U.S. PassportU.S. Certificate of Naturalization or CitizenshipPermanent Resident Card (Green Card) f.Certificate umber g.Expiration ate 1.Have you attached Yes No A copy of your alcohol awareness training certificate of completion? Clean Hands Certification? Yes No Completed/Notarized copy of your Personal Information Release Authorization form Yes No 1.ave you been convicted of a misdemeanor or a felony since the last renewal? Yes No 1.If you answered yes to question 11 please submit a detailed explanation 1.Certification I hereby certify under perjury that the information in this application and attachments are true and correct to the best ofmy knowledge and belief. I will also conform to all laws and regulations related to the alcohol and beverage license for which Ihaveapplied. Subscribed and sworn to before me My commission Signature on this day of, 20. Notary Public expires on 1.In what language do you need vital documents translated? American LegalNet, Inc. www.FormsWorkFlow.com PERSONAL INFORMATION RELEASE AUTHORIZATION CAREFULLY READ THIS AUTHORIZATION TO RELEASE INFORMATION ABOUT YOU, THEN SIGN AND DATE IN INK. I authorize any agent from the Alcoholic Beverage Regulation Administrationto obtain any informationrelating to my activities from employers, criminal justice agencies, financial or lending institutions, credit bureaus, consumer reporting agencies and retail business establishments, or individuals. This information may include, but is not limited to, my residential, personal, or criminal history record and financial and credit information. I further authorize release of my criminal history from criminal justice agencies for the purposes of determining my eligibility for a liquor license as either a licensee and/or investor. I understand that the information released is for official use by the Alcoholic Beverage Regulation Administration, and that these users may re-disclose this information as authorized by law. I release any individual, including records custodians, from all liability for damages that may result to me because of compliance, or any attempts to comply, with this authorization. This release is binding, now and in the future, on my heirs, assignees, associates and personal representative(s) of any nature. Copies of the authorization that show my signature are as valid as the original release signed by me. Failure to complete this form may result in delays of obtaining your license and may result in the license being denied if this information cannot otherwise be obtained. Signature Social Security Number Full Name (Print or type) Other Names Used(Print or type) Current Address Home Telephone Number Date I hereby certify under penalty of perjury that the foregoing information is true and correct. I further, hereby, authorize the Alcoholic Beverage Control Board or its employees to investigate any and all of the information provided by me in this application for an ABC License. Subscribed and sworn to before me My commission Signature on this day of, 20. Not ary Public expires on . American LegalNet, Inc. www.FormsWorkFlow.com CLEAN HANDS CERTIFICATION ALL INDIVIDUALS THAT HAVE AN OWNERSHIP INTEREST MUST COMPLETE THIS FORM. PLEASE READ CAREFULLY AND COMPLETELY BEFORE SIGNING. A FALSE STATEMENT ON THIS CERTIFICATION REQUIRES THAT THE ADMINISTRATION PROCEED IMMEDIATELY TO REVOKE THE LICENSE OR PERMIT FOR WHICH YOU ARE NOW APPLYING, AND FINE YOU $1,000.00. THIS CERTIFICATION IS REQUIRED BY THE CLEAN HANDS ACT OF 1996; EFFECTIVE MAY 11, 1996, (D.C. LAW 11-118, D.C. OFFICIAL CODE SEC. 47-2861 et seq.) BEFORE YOU ARE ELIGIBLE TO RECEIVE A LICENSE OR PERMIT. I, , , (Name residing at , with Social Security Number (Home Address) certify that as of this date, do not owe more than $100.00 to the District of Columbia Government as a result of: 1.Fines, penalties or interest assessed pursuant to the Litter Control Administrative Act of 1985, effective March 25,1986 (D.C. Law 6-100; D.C. Official Code Sec. 8-801 et seq.);2.Fines, penalties or interest assessed pursuant to the illegal Dumping Enforcement Act of 1994, effective May 20,1994 (D.C. Law 10-117; D.C. Official Code Sec. 8-901 et seq.);3.Fines, penalties or interest assessed pursuant to the Department of Consumer & Regulatory Affairs Civil InfractionAct of 1985, effective October 5, 1985 (D.C. Law 6-42; D.C. Official Code Sec. 2-1801.01 et seq.); or4.Past due taxes;5.Past due District of Columbia Water and Sewer Authority Service Fees;6.Traffic adjudication fines or penalties;7.Parking fines or penalties assessed by other jurisdictions, provided, that a reciprocity agreement is in effect betweenthe jurisdiction and the District;8.Fines assessed to car dealers; and9.Fines assessed pursuant to the Taxicab and Limousine Commission Establishment Amendment Act of 2004. I understand that if I knowingly falsify this Certification, the Administration will move to revoke the license or permit for which I am applying and fine me $1,000. I further understand that the Administration may conduct an investigation to ascertain the veracity of this Certification. I understand that this Certification is required as documentation to accompany my application for a license or permit, and that by completing this Certification, I am not guaranteed that my license or permit will be approved. Signature Print Name/Title ABC Application Number ABC License Number FOR OFFICIAL USE ONLY OFFICE OF TAX & REVENUE (OTR) SIGNATURE DATE American LegalNet, Inc. www.FormsWorkFlow.com