20___ STATE OF Vermont Department of Liquor Control APPLICATION FOR THIRD CLASS LICENSE License Year: May 1st through April 30th the following year. Annual Fee $880.00 $440.00 fee for establishment open for six continuous months or less of license year. $440.00 fee for ANY LICENSE issued on or after November 1st. Print Full Name of Person, Partnership, Corp. or Club Doing Business As – Trade Name Street & number of premises covered by application Town or City & Zip Code Make check payable to and mail to: Vermont Department of Liquor Control Green Mountain Drive, Drawer 20 Montpelier, Vermont 05620-4501 Telephone Number Mailing Address (if different from above) Circle one: RESTAURANT CABARET HOTEL CLUB To the Liquor Control Board, Montpelier, Vermont Application is hereby made for a third class license to sell spirituous beverages under and in accordance with Title 7 of the Vermont Statutes Annotated, as amended, and certify that all statements, information and answers to questions herein contained are true; and in consideration of such license being granted do promise and agree to comply with all local and state laws; and to comply with all regulations made and promulgated by the Liquor Control Board. Upon hearing, the Liquor Control Board may, in its discretion, suspend or revoke such license whenever it may determine that the law or regulations of the Liquor Control Board have been violated, or that any statement, information or answers herein contained are false. APPLICATION FOR A FIRST CLASS LICENSE COVERING THE PREMISES IDENTIFIED ABOVE HAS BEEN FILED WITH THE LOCAL BOARD OF CONTROL COMMISSIONERS IN THE TOWN OR CITY OF ____________________ AND THOSE STATEMENTS ARE HEREBY MADE A PART OF THIS THIRD CLASS APPLICATION. FOR CLUBS ONLY: Clubs, as defined in Title 7, Chapter 1, Section 2(6) must answer or comply with the following: Are you an unincorporated association? Or a Vermont corporation? Are you registered with the Secretary of State? Is the salary of any employee contingent upon the profits derived from the sale of alcoholic liquors? YOU MUST ATTACH HERETO A LIST OF THE NAMES AND RESIDENCES OF PAID UP MEMBERS, A LIST OF CLUB OFFICERS, AND A LIST OF EMPLOYEES OF THE CLUB AND THEIR ANNUAL SALARIES. *FOR CABARETS ONLY: Applicant hereby certifies that: The sale of food shall be less in amount or volume than the sales of alcoholic beverages and the receipts from entertainment and dancing; and that if at any time this should not be the case, the applicant-licensee shall immediately notify the Department of Liquor Control of this fact. ALL APPLICANTS MUST COMPLETE AND SIGN I/We hereby certify that the information in this application is true and complete. Dated at in the County of State of Vermont, this day of Signature of authorized agent of corporation, club or association, and , 20 Signature of individual or partners (Title) American LegalNet, Inc. www.FormsWorkflow.com