permit applications returned for any reason may result in a loss of priority on the quota list.SELECT CLASSES YOU WISH TO APPLY FOR: LIQ-18-0020DLC 4113 Page 1 ge Permit C-1 - $252.00 C-2 - $376.00 wnship:c' Carryout Quota Classes:Restaurant & Bar Quota Classes: Entertainment District:D-5L - $2,344.00 (RD)Name of Revitalization District: D-1 - $376.00D-2 - $564.00 1:00am D-3 - $750.00 1:00am D-3A - $938.00 - w/D-3D-5 - $2,344.00 2:30amD-5J - $2,344.00 (CED)Name of Community 1:00am2:30am 614 | 644 3155 Fax 614 | 644 3166 TTY/TDD 800 | 750 0750 www.com.ohio.govAn Equal Opportunity Employer and Service Provider6606 Tussing RoadPO Box 4005Reynoldsburg, OH 43068-9005 U.S.A.Revised 5/13/2019 American LegalNet, Inc. www.FormsWorkFlow.com YESNO Does the applicant or any partner, office holder, 5% or more shareholder, managing member, 5% or more member, or 5% or more voting interest holder in a limited liability company, spouse, or other person involved in this permit hold or have any interest in another permit business currently or previously issued? Give permit number & business address YESNOYESNO 2. Has the applicant or any partner, office holder, 5% or more shareholder, managing member, 5% or more member,or 5% or more voting interest holder in a limited liability company, spouse, or other person involved in this permit ever been convicted of a felony or misdemeanor, including any alcohol-related offenses? please give a detailed explanation: 3. Will the spouse of a sole proprietor, partner, office holder, 5% or more shareholder, managing member,5% or more member or 5% or more voting interest holder in a limited liability company, work on the permitpremises?If YES, submit a personal history background form DLC 4121 for those individuals.4. Has the applicant or any partner, office holder, 5% or more shareholder, managing member, 5% or more member, or 5% or more voting interest holder in a limited liability company, spouse, or other person involved in this permitever been refused a permit, denied a renewal, or had a permit revoked by this Division or the Liquor Control Commission?If YES, please give a detailed explanation: 7. Will the applicant be the sole owner of the equipment? Failure to disclose ownership interest may be a criminal offense under Ohio Revised Code Section 4303.293CERTIFICATION OF FORM:By signing below, I certify that I have authority to execute this document and the information provided is true, correct andcomplete to the best of my knowledge and belief. American LegalNet, Inc. www.FormsWorkFlow.com