Alcoholic Beverage Control Board 5848 E Tudor Rd Anchorage AK 99507 PAGE 1 of 2 907 269-0350 Fax: 907 272-9412 www.dps.state.ak.us/abc LODGE Liquor License This application is for:  Seasonal – Two 6-month periods in each year of the biennial period beginning ___________ and ending __________  Full 2-year period Mo/Day Mo/Day SECTION A. LICENSE INFORMATION. Must be completed. License Number: License Year: FEES Statute Reference: Sec. 04.11.225 Federal EIN or SSN: $1250.00 Filing Fee: (Please leave License # blank) License Fee: $100.00 Fingerprint Fee: ($54.25 per person) _____________ Total Submitted: $ City/Borough/Location information: City:___________________________________________ Borough:_____________________________________________ If you are outside an organized city or borough, you must provide the following: Nearest City or Borough: ________________________________________________________________________________________________ Distance (in miles) from nearest city or borough: _____________________________________________________________________________ Latitude/Longitude (if known): ___________________________________________________________________________________________ Please provide the address or a detailed graphic description of your premise location: Name of Licensee (Corp/LLC/LP/LLP/Individual): Doing Business As (Business Name): Business Telephone Number: Mailing Address: Street Address or Location of Premise: Fax Number: City, State, Zip: Email Address: SECTION C. Individual, corporate officer, director, limited liability organization member, manager or partner background. Does any individual, corporate officer, director, shareholder, limited liability organization member, manager, or any partner named in this application have any direct or indirect interest in any other alcoholic beverage business licensed in Alaska or any other state? List below: Name - State  NO  YES  NO Name - State Has any person named in this application been convicted of a felony, AS 04 violation, or convicted as licensee/manager of any other licensed premise in another state under the liquor laws of that state? Please attach written explanation. Revised 02/12  YES LODGE American LegalNet, Inc. www.FormsWorkFlow.com Alcoholic Beverage Control Board 5848 E Tudor Rd Anchorage AK 99507 907 269-0350 Fax: 907 272-9412 PAGE 2 of 2 LODGE Liquor License Licensee Information www.dps.state.ak.us/abc Corporations, LLCs, LLPs and LLPs must be registered with the Dept. of Community and Economic Development. Name of Entity (Corporation/LLC/LLP/LP) (or N/A if an Individual ownership) Telephone Number Fax Number Corporate Mailing Address: State Zip Code Date of Incorporation OR Certification with DCED State of Incorporation City Name, Mailing Address and Telephone Number of Registered Agent Is the Entity in compliance with the reporting requirements of Title 10 of the Alaska Statutes? Yes Your entity must be in compliance with Title 10 of the Alaska Statutes to be a valid liquor licensee.  No If no, attach written explanation. Entity Members (Must include President, Secretary, Treasurer, Vice-President, Manager and Shareholder/Member with at least 10%) Name Title % Home Address & Telephone Number Work Telephone Number Date of Birth NOTE: On a separate sheet provide information on ownership other organized entities that are shareholders of the licensee. Individual Licensees/Affiliates (The ABC Board defines an “Affiliate” as the spouse of a licensee. Each Affiliate must be listed.) Name: Applicant  Name: Applicant  Address: Affiliate  Address: Affiliate  Home Phone: Work Phone: Name: Address: Home Phone: Work Phone: Applicant  Affiliate  Home Phone: Work Phone: Name: Address: Applicant  Affiliate  Home Phone: Work Phone: Declaration  I declare under penalty of perjury that I have examined this application, including the accompanying schedules and statements, and to the best of my knowledge and belief it is true, correct and complete, and this application is not in violation of any security interest or other contracted obligations.  I hereby certify that there have been no changes in officers or stockholders that have not been reported to the Alcoholic Beverage Control Board. The undersigned certifies on behalf of the corporation, it is understood that a misrepresentation of fact is cause for rejection of this application or revocation of any license issued.  I further certify that I have read and am familiar with Title 4 of the Alaska statutes and its regulations, and that in accordance with AS 04.11.450, no person other than the licensee(s) has any direct or indirect financial interest in the licensed business.  I agree to provide all information required by the Alcoholic Beverage Control Board in support of this application. Signature of Licensee(s) Signature Signature Name & Title (Please Print) Name & Title (Please Print) Subscribed and sworn to before me this Subscribed and sworn to before me this ______ day of ________________, _________. ______ day of ________________, _________. Notary Public in and for the State of Alaska Notary Public in and for the State of Alaska My commission expires: My commission expires: Revised 02/12 Lodge American LegalNet, Inc. www.FormsWorkFlow.com