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 OUT-OF-STATE PRODUCERS EXPORTERS OR RECTIFIERS SECTION 1 This application is for a: SECTION 2 Type of ownership: New License (More than 50 cases per calendar year) New License (50 cases or less per calendar year) (2L) Agent Change SECTION 3 Fees: Individual Partnership Name Corporation Name ALL OUT OF STATE LICENSES EXPIRE ON NOVEMBER 30, FAILURE TO RENEW WILL RESULT IN LATE PENALTIES A service fee of $25.00 will be charged for all dishonored checks (A.R.S. 44-6852) FEES: Regular Out-of-State: Application Approval Date: 2L (50 cases or less per calendar year): Dec. – May $150.00 Jun. – Nov. $137.50 Dec. – May $350.00 Jun. – Nov. $325.00 Annual Renewal $120.00 Agent Change $100.00 Annual Renewal $ 95.00 Agent Change $100.00 NOTE: If your license is approved before November 30, it is mandatory that the license be renewed for the subsequent year. SECTION 4 Applicant: 1. Applicant/Agent's Name: (Insert one name ONLY to appear on license) Last First Middle 2. Business Name: (Exactly as it appears on the exterior of premises) 3. Business Address: (Do not use P.O. box Number Street City State Zip City State Zip 4. Mailing Address: (All correspondence will be mailed to this address) 5. Business Phone: ( 6. Federal ATF Permit #: ) Street Residence Phone: ( ) Your State Liquor License #: ATTACH A COPY OF YOUR LICENSE THAT PERMITS YOU TO DEAL IN SPIRITUOUS LIQUOR IN YOUR HOME STATE. (Continued on back) Lic0112 05/2004 Disabled individuals requiring special accommodations please call (602) 542-9027 American LegalNet, Inc. www.FormsWorkflow.com SECTION 5 All questions MUST be answered. 1. Have you EVER had an application for any business, professional, or liquor license rejected, denied, suspended, or revoked? YES NO 2. Has anyone EVER filed suit or obtained a judgment against you in any Civil action, the subject of which involved fraud or misrepresentation of a liquor license? YES NO 3. Have you EVER been charged with or convicted of a felony? YES NO 5. Are you familiar with Arizona State Liquor Laws and Regulations? YES NO 6. Do you agree to notify the Department of Liquor of any proposed change of ownership or other changes prior to making any such changes? YES NO 7. Do you agree to keep all records, invoices, and other documents relating to the purchase, sale, or delivery of spirituous liquor for a period of two years and to have them easily accessible for examination? YES NO 8. Do you consent to an investigation of your background including all records of every kind and description including police records and to waive any rights or causes of action that you may have against the Department of Liquor Licenses and Control and any other individual or agency disclosing or releasing said information to the Department? YES NO 4. If you answered 'YES' to questions 1, 2, or 3, give complete details: (Attach additional sheets if necessary) 9. If you answered 'NO' to any of questions 5, 6, 7, or 8 give complete details: (Attach additional sheets if necessary) FALSE OR INCOMPLETE ANSWERS COULD RESULT IN CRIMINAL PROSECUTION AND THE DENIAL OR SUBSEQUENT REVOCATION OF A LICENSE OR PERMIT. I, , being first duly sworn upon oath, hereby depose, (Print Name) swear and declare under penalty of perjury, that I am the APPLICANT making the forgoing application. I have read this application and the contents and all statements are true, correct and complete. State of X County of The foregoing instrument was acknowledged before me this (Signature) Day Month Year My commission expires on: MM/DD/YY Signature of NOTARY PUBLIC American LegalNet, Inc. www.FormsWorkflow.com