Alcoholic Beverage Control Board 5848 E Tudor Rd Anchorage, AK 99507 PAGE 1 OF 2 Renewal Liquor License (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 Type: FEES License #: ___________ Local Governing Body: (City, Borough or Unorganized) Statute Reference License Fee: $ Sec. 04.11.__________ License Renewal Period (new): Filing Fee: $200.00 Community Council Name(s) & Mailing Address: {If applicable} 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: Has the license been exercised or active at least 30 eight-hour days during each of the two preceding calendar years? [AS 04.11.330(3)] Yes No If No, your application will be denied unless a Waiver of Operation (form available) is approved by the Alcoholic Beverage Control Board. SECTION B - RENEWAL INFORMATION PACKAGE STORE: Does this renewal include Has the licensed premises been changed from Has there been any change in ownership renewal of the notice required under AS04.11.150(a) the last diagram submitted? interest since the last application submitted? Yes No If yes, submit a new diagram to sell alcoholic beverages in response to written orders? Yes No Yes No SECTION C - Individual, corporate officer, limited liability organization member, manager or partner background. Does any individual, corporate officer, director, limited 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 If Yes, complete the following. Attach additional sheets if necessary. No Name 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 If Yes, attach written explanation. No Date Approved Director’s Signature Renewal App 11/05 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: Renewal App 11/05 American LegalNet, Inc. www.FormsWorkflow.com