STATE OF MAINE Liquor Licensing & Inspection Division 164 State House Station Augusta ME 04333-0164 Tel: (207) 624-7220 Fax: (207) 287-3424 MAINE DEPT OF PUBLIC SAFETY BUREAU USE ONLY ‫ ڤ‬AGENCY LIQUOR STORE RENEWAL $300.00 License No. Assigned: ‫ ڤ‬RESELLING AGENT - $50.00 CHECK PAYABLE: TREASURER STATE OF MAINE PRESENT LICENSE EXPIRES ________________ Class: Deposit Date: Amount Deposited: ALL QUESTIONS MUST BE ANSWERED IN FULL 1. APPLICANT(S) –(Sole Proprietor, Corporation, Limited Liability Co., 2. Business Name (D/B/A) etc.) DOB: DOB: Location (Street Address) DOB: Address City/Town State Zip Code State Zip Code Mailing Address City/Town State Telephone Number Zip Code FAX: City/Town Business Telephone Number Federal I.D. # FAX: Seller Certificate # 3. Is applicant a Corporation, Limited Liability Company or Limited Partnership? If answer is “yes”, complete Supplementary Questionnaire. Yes ‫ ڤ‬No ‫ڤ‬ 4. Have any changes occurred in Ownership, Partnership or Corporate structure since last renewal? Yes ‫ ڤ‬No ‫ڤ‬ 5. List current annual dollar sales of: Retail sales: $ ______________ Wholesale/Licensee sales: $ _______________ 6. List current on-hand inventory of spirits, in dollars: $ _______________ 7. Basic Federal Permit # _______________ Federal Tax Stamp EIN # _______________ Tax Year 20 _____ Dated at: ______________________________________________ on ____________________ , 20 _____ Town/City, State __________________________________________ Month/Day ________________________________________________ Signature of Individual(s) or Duly Authorized Officer of Corporation or, if Partnership, by Member NOTE: I understand that false statements made on this form are punishable by law. Knowingly supplying false information on this form is a Class D offense under the Criminal Code, punishable by confinement of up to one year, or by monetary fine of up to $2000, or by both. AgncyRenApp / 2003 American LegalNet, Inc. www.FormsWorkflow.com