WLD- 28 (7/06) -----FOR RENEWALS ONLY----- RENEWAL OF LICENSE AND/OR PERMIT APPLICATION FOR LIQUOR, WINERY OR MICROBREWERY NOTE TO APPLICANT: To be filed with the local licensing authority. (Hearing must be 30 days prior to expiration) Applicant: To be completed by the City, Town or County Clerk: Date filed: / / Annual Fee Trade Name (dba): Basic Fee Additional Disp Rm Fee Total Lic Fee Collected Publishing Fee Collected Required attachments received Advertising Dates (4) Hearing Date Local Licensing Number Premise: Number & Street City / State / Zip / County Mailing Address: YES Number & Street or P.O. Box City / State / Zip LICENSING AUTHORITY: Begin publication promptly. As W.S. 12-4-104(d) specifies NO LICENSING AUTHORITY SHALL APPROVE OR DENY THE APPLICATION UNTIL THE LIQUOR DIVISION HAS CERTIFIED THE APPLICATION IS COMPLETE. Copy must be immediately forwarded to: CITY OF COUNTY OF FILING AS (Choose only one) INDIVIDUAL PARTNERSHIP CORPORATION LTD PARTNERSHIP LLC LLP LOCATED WITHIN 5 MILES OF CITY Fax Number: E-Mail Address: For the license term from: / / Through: STATE OF WYOMING LIQUOR DIVISION 1520 E 5TH ST CHEYENNE, WY 82002-0110 FILING IN (Choose only one) Business Telephone Number: / / TYPE OF LICENSE OR PERMIT (Choose only one) RETAIL LIQUOR LICENSE RESTAURANT LIQUOR LICENSE RESORT LIQUOR LICENSE COUNTY RETAIL or SPECIAL MALT BEVERAGE PERMIT VETERANS CLUB FRATERNAL CLUB GOLF CLUB SOCIAL CLUB MICROBREWERY WINERY BAR AND GRILL To Assist the Liquor Division with scheduling inspections: DO YOU OPERATE? FULLTIME(e.g. Jan through Dec) SEASONAL/PART-TIME (specify months of operation) from to DAYS OF WEEK(e.g. Mon through Sat) HOURS OF OPERATION(e.g. 10a - 2a) RETAIL: (ON PREMISE ONLY) (OFF PREMISE ONLY) (COMBINATION ON/OFF PREMISE) Have you purchased $2,000 in spirits, wines and/or malt beverages during the previous license term? YES NO RESTAURANT, RESORT, CLUB, COUNTY MALT, OR BAR AND GRILL: YES NO Have you purchased $500 in spirits, wines and/or malt beverages during the previous license term? W.S.12-4-103(c) TO BE COMPLETED BY APPLICANTS {Pursuant to W.S.12-4-102(a)} 1. Location of License: a) Give a description of the dispensing room and state where it is located in the building (ex. 10’ X 12’ room in SE corner of 1st floor of bldg). If the building is not in existence, provide the location and an architect’s drawing or suitable plans of the room and premises to be licensed: If Winery or Microbrewery also list manufacturing facility. (W.S.12-4-102(a)(i): b) Do you have an additional dispensing room? YES NO If yes, provide description and location: c) Provide the legal description and the zoning of the site where the applicant will sell under the license: W.S.12-4-102(a)(vii) 2. Have there been any changes in the physical location of the dispensing room since the last application was filed? YES NO (If yes, submit a drawing of the changes in the dispensing room.) YES NO a) Do you anticipate any changes in the next twelve (12) months? 3. If the premises are not owned by licensee, attach a copy of the lease agreement which shows that the right to occupy the premises continues through the term of the license and contains an agreement that alcoholic or malt beverages may be sold upon the leased premises. Please indicate the page and paragraph of lease that shows the date of expiration. W.S.12-4-103(a)(iii) a) DATE lease expires: ______/______/______, located on page ______, paragraph ______ of lease document. b) Provision for SALE of alcohol or malt beverages located on page ______, paragraph ______ of lease document. American LegalNet, Inc. www.FormsWorkflow.com WLD- 28 (7/06) 4. Restaurant and Bar and Grill Liquor Licenses Only: a) Gross sales figures and percentages of income derived from: W.S.12-4-408(b) Gross Sales: $___________ Food Sales: $___________(_______%) Liquor Sales: $___________(_______%) b) Attach a copy of your valid food service permit to this application. W.S.12-4-407(a), W.S.12-4-413(a) 5. If applicant is a Microbrewery: a) Did you produce over 100 barrels (3,100 gallons) but less than 15,000 barrels (465,000 gallons during the previous YES NO license term? W.S.12-1-101(a)(xix) YES NO b) Do you self distribute your products? YES NO c) Do you distribute your own products through an existing malt beverage wholesaler? 6. If applicant is an Individual(s) or Partnership: State the name, date of birth and residence of the applicant and of each applicant or partner, if the application is made by more than one individual or partnership. If the application is for a Club: State the name, date of birth and residence of each officer. True and Correct Name Date of Birth Residence Phone Number DO NOT LIST PO BOXES Residence Address, Street, City, State & Zip Have you been a DOMICILED resident for at least 1 year and not claimed residence in any other State in the last year? Have you been Convicted of a Felony Violation? YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO Have you been Convicted of a Violation Relating to Alcoholic Liquor or Malt Beverages? YES NO YES NO YES NO YES NO (If more information is required, complete in identical form, on a separate piece of paper and attach to this application.) 7. If the applicant is a Corporation, Limited Liability Company, Limited Liability Partnership or Limited Partnership: State the name, date of birth and residence of each stockholder holding, either jointly or severally, ten percent (10%) or more of the outstanding and issued capital stock of the corporation, limited liability company, limited liability partnership, or limited partnership, and every officer, and every director. True and Correct Name Date of Birth DO NOT LIST PO BOXES Residence Address, Street, City, State & Zip Residence Phone Number No of years in corp or LLC % of Stock Held Have you been Convicted of a Felony Violation? YES NO YES NO YES NO YES NO Have you been Convicted of a Violation Relating to Alcoholic Liquor or Malt Beverages? YES NO YES NO YES NO YES NO (If more information is required, complete in identical form, on a separate piece of paper and attach to this application.) VERIFICATION OF APPLICATION (Requires signatures by ALL Individuals, ALL Partners, TWO (2) LLC Members, TWO (2) Corporate Officers/Directors, or TWO (2) Club Officers.) W.S.12-4-102(b) Under penalty of perjury, and the possible revocation or cancellation of the license, I swear the above stated facts, are true and accurate. Dated this _______ day of _______________, _______. ________________________________________________ Applicant THE STATE OF WYOMING COUNTY OF SS. ________________________________________________ Applicant Subscribed and sworn to before me by ____________________________ this _______ day of _______________, _______. Witness my hand and official seal. __________________________________________________________ Notary Public or Person Authorized to Administer Oath My Commission expires: _______________________________ FOR LIQUOR DIVISION USE ONLY Reviewer Initials Date Clerk: Agent: Credit: American LegalNet, Inc. www.FormsWorkflow.com