American LegalNet, Inc. www.FormsWorkFlow.com SECTION 5 Interim Permit: 1. If you intend to operate business when your application is pending you will need an Interim Permit pursuant to A.R.S. 4-203.01. 2. There MUST be a valid license of the same type you are applying for currently issued to the location. 3. Enter the license number currently at the location._____________________ 4. Is the license currently in use? YES NO If no, how long has it been out of use?_________________ ATTACH THE LICENSE CURRENTLY ISSUED AT THE LOCATION TO THIS APPLICATION. I , ________________________ , declare that I am the CURRENT OWNER, AGENT, CLUB MEMBER, PARTNER, (Print full name) MEMBER, STOCKHOLDER, OR LICENSEE (circle the title which applies) of the stated license and location. State of ____________ County of_______________ X________________________________ The foregoing instrument was acknowledged before me this (Signature) _____day of ____________, Day Month My commission expires on: __________________ ________ Year ________________________________ (Signature of NOTARY PUBLIC) SECTION 6 Individual or Partnership Owners: EACH PERSON LISTED MUST SUBMIT A COMPLETED QUESTIONNAIRE (FORM LIC0101), AN "APPLICANT" TYPE FINGERPRINT CARD, AND $24 PROCESSING FEE FOR EACH CARD. 1. Individual: Last First Middle % Owned Mailing Address City State Zip Partnership Name: (Only the first partner listed will appear on license) ________________________________________________ General-Limited Last First Middle % Owned Mailing Address City State Zip (ATTACH ADDITIONAL SHEET IF NECESSARY) 2. Is any person, other than the above, going to share in the profits/losses of the business? YES NO If Yes, give name, current address and telephone number of the person(s). Use additional sheets if necessary. Last First Middle Mailing Address 2 City, State, Zip Telephone# American LegalNet, Inc. www.FormsWorkFlow.com SECTION 7 Corporation/Limited Liability Co.: EACH PERSON LISTED MUST SUBMIT A COMPLETED QUESTIONNAIRE (FORM LIC0101), AN “APPLICANT” TYPE FINGERPRINT CARD, AND $24 PROCESSING FEE FOR EACH CARD. CORPORATION Complete questions 1, 2, 3, 5, 6, 7, and 8. L.L.C. Complete 1, 2, 4, 5, 6, 7, and 8. 1. Name of Corporation/L.L.C.: ___________________________________________________________________ (Exactly as it appears on Articles of Incorporation or Articles of Organization) 2. Date Incorporated/Organized: _______________ State where Incorporated/Organized: __________________________ 3. AZ Corporation Commission File No.: ________________________ Date authorized to do business in AZ: ___________ 4. AZ L.L.C. File No: _________________________________ Date authorized to do business in AZ: _________________ 5. Is Corp./L.L.C. Non-profit? YES NO 6. List all directors, officers and members in Corporation/L.L.C.: Last First Middle Mailing Address Title City State Zip (ATTACH ADDITIONAL SHEET IF NECESSARY) 7. List stockholders who are controlling persons or who own 10% or more: Last First Middle % Owned Mailing Address City State Zip (ATTACH ADDITIONAL SHEET IF NECESSARY) 8. If the corporation/L.L.C. is owned by another entity, attach a percentage of ownership chart, and a director/officer/member disclosure for the parent entity. Attach additional sheets as needed in order to disclose personal identities of all owners. SECTION 8 Club Applicants: EACH PERSON LISTED MUST SUBMIT A COMPLETED QUESTIONNAIRE (FORM LIC0101), AN “APPLICANT” TYPE FINGERPRINT CARD, AND $24 PROCESSING FEE FOR EACH CARD. 1. Name of Club: ___________________________________________________ Date Chartered: ___________________ (Exactly as it appears on Club Charter or Bylaws) 2. Is club non-profit? YES (Attach a copy of Club Charter or Bylaws) NO 3. List officer and directors: Last First Middle (ATTACH ADDITIONAL SHEET IF NECESSARY) Title Mailing Address 3 City State Zip American LegalNet, Inc. www.FormsWorkFlow.com SECTION 9 Probate, Will Assignment or Divorce Decree of an existing Bar or Liquor Store License: 1. Current Licensee's Name: __________________________________________________________________________ (Exactly as it appears on license) Last First Middle 2. Assignee's Name: ________________________________________________________________________________ Last 3. License Type: ____________ First Middle License Number: _________________ Date of Last Renewal: ________________ 4. ATTACH TO THIS APPLICATION A CERTIFIED COPY OF THE WILL, PROBATE DISTRIBUTION INSTRUMENT, OR DIVORCE DECREE THAT SPECIFICALLY DISTRIBUTES THE LIQUOR LICENSE TO THE ASSIGNEE TO THIS APPLICATION. SECTION 10 Government: (for cities, towns, or counties only) 1. Governmental Entity: 2. Person/designee: Last First Middle Contact Phone Number A SEPARATE LICENSE MUST BE OBTAINED FOR EACH PREMISES FROM WHICH SPIRITUOUS LIQUOR IS SERVED. SECTION 11 Person to Person Transfer: Questions to be completed by CURRENT LICENSEE (Bars and Liquor Stores ONLY-Series 06,07, and 09). 1. Current Licensee's Name: (Exactly as it appears on license) Entity: Last First Middle (Indiv., Agent, etc.) 2. Corporation/L.L.C. Name: (Exactly as it appears on license) 3. Current Business Name: (Exactly as it appears on license) 4. Physical Street Location of Business: Street City, State, Zip 5. License Type: ____________________ License Number: 6. If more than one license to be transfered: License Type: __________________ License Number: _____________________ 7. Current Mailing Address: (Other than business) Street City, State, Zip 8. Have all creditors, lien holders, interest holders, etc. been notified of this transfer? YES NO 9. Does the applicant intend to operate the business while this application is pending? 5 of this application, attach fee, and current license to this application. YES NO If yes, complete Section 10. I, _______________________________________, hereby authorize the department to process this application to transfer the (print full name) privilege of the license to the applicant, provided that all terms and conditions of sale are met. Based on the fulfillment of these conditions, I certify that the applicant now owns or will own the property rights of the license by the date of issue. I, _______________________________________, declare that I am the CURRENT OWNER, AGENT, MEMBER, PARTNER (print full name) STOCKHOLDER, or LICENSEE of the stated license. I have read the above Section 11 and confirm that all statements are true, correct, and complete. State of ______________County of _______________ The foregoing instrument was acknowledged before me this (Signature of CURRENT LICENSEE) Day Month Year My commission expires on: 4 (Signature of NOTARY PUBLIC) American LegalNet, Inc. www.FormsWorkFlow.com SECTION 12 Location to Location Transfer: (Bars and Liquor Stores ONLY) APPLICANTS CANNOT OPERATE UNDER A LOCATION TRANSFER UNTIL IT IS APPROVED BY THE STATE 1. Current Business: Name __________________________________________________________________ (Exactly as it appears on license) Address _________________________________________________________________ 2. New Business: Name __________________________________________________________________ (Physical Street Location) Address _________________________________________________________________ 3. License Type: ______________ License Number: _______________________ 4. If more than one license to be transferred: License Type:___________________ License Number: ___________________ 5. What date do you plan to move? ____________________________ What date do you plan to open? _________________ SECTION 13 Questions for all in-state applicants excluding those applying for government, hotel/motel, and restaurant licenses (series 5, 11, and 12): A.R.S. § 4-207 (A) and (B) state that no retailer’s license shall be issued for any premises which are at the time the license application is received by the director, within three hundred (300) horizontal feet of a church, within three hundred (300) horizontal feet of a public or private school building with kindergarten programs or grades one (1) through (12) or within three hundred (300) horizonal feet of a fenced recreational area adjacent to such school building. The above paragraph DOES NOT apply to: a) Restaurant license (§ 4-205.02) b) Hotel/motel license (§ 4-205.01) c) Government license (§ 4-205.03) d) Fenced playing area of a golf course (§ 4-207 (B)(5)) 1. Distance to nearest school: _________ ft. Name of school ___________________________________________ Address _____________________________________________________ City, State, Zip 2. Distance to nearest church: _________ ft. 3. I am the: Lessee Name of church __________________________________________ Address _____________________________________________________ City, State, Zip Sublessee Owner Purchaser (of premises) 4. If the premises is leased give lessors: Name ______________________________________________________________ Address ____________________________________________________________ City, State, Zip 4a. Monthly rental/lease rate $_____________ What is the remaining length of the lease __ yrs. ____mos. 4b. What is the penalty if the lease is not fulfilled? $____________ or other _____________________________ (give details - attach additional sheet if necessary) 5. What is the total business indebtedness for this license/location excluding the lease? $_________________ Please list debtors below if applicable. Last First Middle Amount Owed Mailing Address City State Zip (ATTACH ADDITIONAL SHEET IF NECESSARY) 6. What type of business will this license be used for (be specific)? ______________________________________________ 5 American LegalNet, Inc. www.FormsWorkFlow.com SECTION 13 - continued 7. Has a license or a transfer license for the premises on this application been denied by the state within the past one (1) year? YES NO If yes, attach explanation. 8. Does any spirituous liquor manufacturer, wholesaler, or employee have any interest in your business? 9. Is the premises currently licensed with a liquor license? YES YES NO NO If yes, give license number and licensee’s name: License #_______________________(exactly as it appears on license) Name ___________________________________ SECTION 14 Restaurant or hotel/motel license applicants: 1. Is there an existing restaurant or hotel/motel liquor license at the proposed location? If yes, give the name of licensee, Agent or a company name: YES NO _______________________________ and license #: Last First Middle 2. If the answer to Question 1 is YES, you may qualify for an Interim Permit to operate while your application is pending; consult A.R.S. § 4-203.01; and complete SECTION 5 of this application. 3. All restaurant and hotel/motel applicants must complete a Restaurant Operation Plan (Form LIC0114) provided by the Department of Liquor Licenses and Control. 4. As stated in A.R.S. § 4-205.02.G.2, a restaurant is an establishment which derives at least 40 percent of its gross revenue from the sale of food. Gross revenue is the revenue derived from all sales of food and spirituous liquor on the licensed premises. By applying for this hotel/motel restaurant license, I certify that I understand that I must maintain a minimum of 40 percent food sales based on these definitions and have included the Restaurant Hotel/Motel Records Required for Audit (form LIC 1013) with this application. __________________________________ applicant’s signature As stated in A.R.S § 4-205.02 (B), I understand it is my responsibility to contact the Department of Liquor Licenses and Control to schedule an inspection when all tables and chairs are on site, kitchen equipment, and, if applicable, patio barriers are in place on the licensed premises. With the exception of the patio barriers, these items are not required to be properly installed for this inspection. Failure to schedule an inspection will delay issuance of the license. If you are not ready for your inspection 90 days after filing your application, please request an extension in writing, specify why the extension is necessary, and the new inspection date you are requesting. To schedule your site inspection visit www.azliquor.gov and click on the “Information” tab. ____________ applicants initials SECTION 15 Diagram of Premises: (Blueprints not accepted, diagram must be on this form) 1. Check ALL boxes that apply to your business: Entrances/Exits Service windows Liquor storage areas Drive-in windows Patio: Contiguous Non Contiguous 2. Is your licensed premises currently closed due to construction, renovation, or redesign? YES NO If yes, what is your estimated opening date? month/day/year 3. Restaurants and hotel/motel applicants are required to draw a detailed floor plan of the kitchen and dining areas including the locations of all kitchen equipment and dining furniture. Diagram paper is provided on page 7. 4. The diagram (a detailed floor plan) you provide is required to disclose only the area(s) where spiritous liquor is to be sold, served, consumed, dispensed, possessed, or stored on the premises unless it is a restaurant (see #3 above). 5. Provide the square footage or outside dimensions of the licensed premises. Please do not include non-licensed premises, such as parking lots, living quarters, etc. As stated in A.R.S. § 4-207.01(B), I understand it is my responsibility to notify the Department of Liquor Licenses and Control when there are changes to boundaries, entrances, exits, added or deleted doors, windows or service windows,or increase or decrease to the square footage after submitting this initial drawing. 6 ____________ applicants initials American LegalNet, Inc. www.FormsWorkFlow.com SECTION 15 Diagram of Premises 4. In this diagram please show only the area where spirituous liquor is to be sold, served, consumed, dispensed, possessed or stored. It must show all entrances, exits, interior walls, bars, bar stools, hi-top tables, dining tables, dining chairs, the kitchen, dance floor, stage, and game room. Do not include parking lots, living quarters, etc. When completing diagram, North is up . If a legible copy of a rendering or drawing of your diagram of premises is attached to this application, please write the words “diagram attached” in box provided below. _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ SECTION 16 Signature Block I, _________________________________, hereby declare that I am the OWNER/AGENT filing this (print full name of applicant) application as stated in Section 4, Question 1. I have read this application and verify all statements to be true, correct and complete. X_________________________________ (signature of applicant listed in Section 4, Question 1) State of _________________________County of __________________ The foregoing instrument was acknowledged before me this ____________ of _____________________, _____________ Day My commission expires on : _______________________ Day Month Month Year ________________________________________________ Year signature of NOTARY PUBLIC 7 American LegalNet, Inc. www.FormsWorkFlow.com