Department of Alcoholic Beverage Control State of California (ABC Use Only) ADDITIONAL LICENSE/PERMIT APPLICATION Effective July 1, 2012 Revenue and Taxation Code, Section 7057, authorizes the State Board of Equalization and the Franchise Tax Board to share taxpayer information with the Department of Alcoholic Beverage Control. The Department may suspend, revoke, and refuse to issue a license if the licensee's name appears in the 500 largest tax deliquencies list. (Business and Professions Code Section 494.5.) SECTION 1- LICENSEE(S) INFORMATION 1. LICENSEE'S NAME 4. PROPOSED PREMISES ADDRESS 6. MAILING ADDRESS 2. DOING BUSINESS AS (DBA) 3.DATE 5. DISTRICT OFFICE 7. LICENSEE'S PHONE NUMBER LICENSE NUMBER RECEIPT NUMBER FEE PAID COPIES MAILED DATE GEO CODE $ DISTRICT CODE SECTION 2- APPLICATION FOR PERMIT/LICENSE 8. TYPE OF PERMIT/LICENSE 9. NUMBER OF PERMIT/LICENSES 10. PRINCIPAL/MASTER LICENSE NUMBER I/We apply for the permit/license(s) checked below a. Caterer's Permit (Type 58) b. Controlled Access Cabinet (Type 66) c. Portable Bar (Type 68) d. Beer & Wine Importer (Type 09) e. Duplicate (Type 01 or 23) ---f. Brandy Importer (Typer 11) g. Distilled Spirits Importer (Type 12) h. Duplicate (Type 02) i. Duplicate (Type 47) Retail Sales/Tasting location? *Yes j. Duplicate (Type 48) k. Event Permit (Type 77) l. Certified Farmer's Market (Type 79) m. Other No *Beer Manufacturing Temporary Permit requested - please check SECTION 3- SIGNATURE (Only one signature required) 11. CERTIFICATION FOR SIGNATURE OF A LICENSED PRINCIPAL I declare under penalty of perjury that I am authorized to sign for licensed entity identified in Item 1, above. I have read the foregoing and know the contents thereof. Signature must be notorized unless witnessed by ABC employee. 12. SIGNATURE 13. PRINTED NAME AND TITLE 14. DATE ABC USE ONLY RECOMMENDATION AGENT'S SIGNATURE (if investigation required) DATE SIGNED RECOMMENDATION SUPERVISOR'S SIGNATURE DATE SIGNED Distribution: Original to Headquarters Cashier ABC-220 to follow Conditions to follow; Hold in HQ until received ABC-239 (rev. 9/14) American LegalNet, Inc. www.FormsWorkFlow.com