PAGE 1 OF 2 New Liquor License Alcoholic Beverage Control Board 5848 E Tudor Rd Anchorage, AK 99507 (907) 269-0350 Fax: (907) 272-9412 www.dps.state.ak.us/abc 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 for all types of applications. License Year: License Type: Statute Reference License Fee: $ {Office Use Only} Sec. 04.11.__________ Filing Fee: $100.00 License #: ___________ Local Governing Body: (City, Borough or Unorganized) FEES Community Council Name(s) & Mailing Address: Fingerprint: ($59 per person) ___________ Total Submitted: $ Federal EIN or SSN: Name of Applicant (Corp/LLC/LP/LLP/Individual/Partnership): Doing Business As (Business Name): Business Telephone Number: Fax Number: Mailing Address: Street Address or Location of Premise: Email Address: City, State, Zip: SECTION B. PREMISES TO BE LICENSED. Must be completed. Distance measured under: Closest school grounds Premises is GREATER than 50 miles from the boundaries of an AS 04.11.410 OR incorporated city, borough, or unified municipality. Local ordinance No. _____ Premises is LESS than 50 miles from the boundaries of an incorporated Distance measured under: Closest church: city, borough, or unified municipality. AS 04.11.410 OR Not applicable Local ordinance No. _______ Premises to be licensed is: Proposed building Existing facility New building Plans submitted to Fire Marshall (required for new & proposed buildings) Diagram of premises attached SECTION C. Individual, corporate officer, limited liability organization member, manager or partner background. Does any individual, corporate officer, director, imited liability organization member, manager or partner named in this application have any direct or indirect interest in any other alcoholic beverage business licensed in Alaska or any other state? Yes Name No If Yes, complete the following. Attach additional sheets if necessary. Name of Business Type of License Business Street Address State Has any individual, corporate officer, director, limited liability organization member, manager or partner named in this application been convicted of a felony, a violation of AS 04, or been convicted as a licensee or manager of licensed premises in another state of the liquor laws of that state? Yes No If Yes, attach written explanation. Date Approved New App 11/05 Director’s Signature American LegalNet, Inc. www.FormsWorkflow.com Alcoholic Beverage Control Board 5848 E Tudor Rd Anchorage AK 99507 PH: 907 269-0350 - FX: 907 272-9412 PAGE 2 of 2 Liquor License Licensee Information www.dps.state.ak.us/abc Corporations, LLCs, LLPs and LPs 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: Date of Birth: Home Phone: Work Phone: Date of Birth: Applicant Affiliate Home Phone: Work Phone: Name: Address: Date of Birth: Home Phone: Work Phone: Date of Birth: Applicant Affiliate 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 organized entity, 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: New License App 11/05 American LegalNet, Inc. www.FormsWorkflow.com