ARIZONA DEPARTMENT OF LIQUOR LICENSES & CONTROL 400 W Congress #521 Tucson AZ 85701-1352 (520) 628-6595 800 W Washington 5th Floor Phoenix AZ 85007-2934 (602) 542-5141 APPLICATION FOR AGENT CHANGE - ACQUISITION OF CONTROL - RESTRUCTURE Check Appropriate Box Agent Change Complete Sections 1,2,3,4,6 (See Note 1 on back) SECTION 1 Acquisition of Control Restructure Complete Sections 1,2, (3,4 if changing Agent), 6 Complete Sections 1,2,(3,4 if changing Agent) ,5,6 (See Note 2 on back) (COMPLETE THIS SECTION FOR AGENT CHANGE, ACQUISITION OF CONTROL OR RESTRUCTURE) 1. Name (INDIVIDUAL OR EXISTING AGENT (if no agent change) OR NEW AGENT OR CORPORATE OFFICER OR L.L.C. CONTROLLING MEMBER) Last 2. First Corporation L.L.C. Liquor License # Middle N/A: Corp. File #: (Exactly as it appears on Articles of Inc. or Articles of Org.) 3. Business Name: (Exactly as it appears on license) 4. Business Address: (Do not use P.O. Box Number) City COUNTY 5. Is the business located within the incorporated limits of the above city or town? Yes Zip No 6. Mailing Address: City 7. Business Phone: (______) ________________________ State Zip Residence Phone: (_____) 8. Does this transaction involve the sale of any portion of the corporate stock? YES NO N/A If yes, submit a certified copy of minutes. 9. Has there been any change of officers? YES NO N/A If yes, submit a certified copy of minutes. SECTION 2 (COMPLETE THIS SECTION FOR AGENT CHANGE, ACQUISITION OF CONTROL OR RESTRUCTURE) Each person listed in Section II must submit a personal questionnaire (Form LIC0101) and a Department approved fingerprint card which may be obtained at the Dept. A person appearing in both lists need only submit one questionnaire and fingerprint card. 1. List individual owner or partners or all directors, officers in corp., members in LLC: Last First Middle Title Residence Address City State Zip (ATTACH ADDITIONAL SHEET(S) IF NECESSARY) 2. List stockholders or controlling members owning 10% or more of Corp/LLC: Last LIC0102 09/2005 First Middle % Owned Residence Address City State Zip (ATTACH ADDITIONAL SHEET(S) IF NECESSARY) Disabled individuals requiring special accommodations please call the Department Date Received _________________ CSR _________________________ American LegalNet, Inc. www.FormsWorkflow.com SECTION 3 (COMPLETE THIS SECTION FOR AGENT CHANGE ) 1. If the corporation/L.L.C. is owned by another entity, ATTACH AN OWNERSHIP AND DIRECTOR / OFFICER / MEMBER DISCLOSURE for the parent entity. Attach additional sheets as necessary in order to disclose real people. As an Agent, will you be physically present and operating the licensed premises? YES NO If you answered YES, you must provide proof of attendance of a Department approved Liquor Law Training Course within the last five years before your application for Agent can be submitted. If “no” a manager with approved training must be submitted. SECTION 4 (COMPLETE THIS SECTION FOR AGENT CHANGE) To be completed by the INDIVIDUAL OR EXISTING AGENT OR CORPORATE OFFICER OR L.L.C. CONTROLLING MEMBER: 1. License Number: ____________________________ Date of last renewal: 2. Current Licensee or Agent: (Exactly as it appears on license) Last First Middle I, _________________________________________________, hereby consent to the agent appointment named herein and (Print full name) agree to immediately assign a new agent in the event of the death, resignation, or discharge of this agent. I also understand that if the background report shows that I, the corporation, or any officer, director, member, or stockholder have been convicted of a felony in the past five (5) years, I will immediately surrender the license to the Arizona Department of Liquor Licenses and Control and hereby waive all rights to appeal such action. State of__________________County of X______________________________________________ The foregoing instrument was acknowledged before me this (Signature of INDIVIDUAL/ CORPORATE/CLUB OFFICER/MEMBER) ________day of ____________________, Day Month Year My commission expires on: (Signature of NOTARY PUBLIC) SECTION 5 (COMPLETE THIS SECTION FOR RESTRUCTURE) Is there more than one licensed premises involved? paid for each license/location. Type of current ownership: YES NO If yes, SEPARATE APPLICATIONS must be filed and fees Type of new ownership: J.T.W.R.O.S. INDIVIDU AL PARTNERSHIP CORPORATION LIMITED LIABILITY CO. TRUST OTHER Explain SECTION 6 J.T.W.R.O.S. INDIVIDUAL PARTNERSHIP CORPORATION LIMITED LIABILITY CO. TRUST OTHER Explain (COMPLETE THIS SECTION FOR AGENT CHANGE, ACQUISITION OF CONTROL OR RESTRUCTURE) To be completed by INDIVIDUAL OR EXISTING AGENT (if no agent change) OR NEW AGENT OR CORPORATE OFFICER OR L.L.C. CONTROLLING MEMBER as listed in Question 1 Section 1: I, ______________________________________________, hereby declare that I am the APPLICANT filing this application. (Print full name) have read the application and the contents and all statements are true, correct and complete. State of ________________County of X______________________________________________ The foregoing instrument was acknowledged before me this (Signature of INDIVIDUAL OR AGENT) day of Day , Month Year My commission expires on: (Signature of NOTARY PUBLIC) NOTE 1: The fee for an agent change MUST be submitted with this application: $100.00 for the first application and $50.00 for each additional application, not to exceed $1,000.00. (A.R.S. 4-209.H) NOTE 2: The $100.00 fee for restructure MUST be submitted with this application (A.R.S. 4-209.A) American LegalNet, Inc. www.FormsWorkflow.com