Department of Alcoholic Beverage Control APPLICATION QUESTIONNAIREPlease read instructions, which includes Privacy Notice, before completing form.1.APPLICANT'S NAME(S) (If an individual, first name, middle name, last name. Name of entity if corporation, limited partnership or limited liability company.)P-12 LICENSEEYesNo(If yes, complete form ABC-811)2.LICENSE TYPE(S) (Check appropriate items)3.TRANSACTION TYPE (Check appropriate item)20 Off-Sale Beer & WineOriginal (New)21 Off-Sale GeneralPerson-to-Person Transfer (check appropriate section):40 On-Sale BeerSection 24071 (Surviving spouse, corporations, fiduciaries, etc.)41 On-Sale Beer & Wine Eating PlaceSection 24071.1 (Corporate Stock/Limited Partnership)42 On-Sale Beer & Wine Public PremisesSection 24071.2 (Limited Liability Company)47 On-Sale General Eating PlacePremises-to-Premises Transfer48 On-Sale General Public PremisesExchangeOtherOther4.TEMPORARY PERMIT REQUESTED (Person-to-Person transfers only)YesNo5.PREMISES ADDRESS (Where license to be issued) (Street number and name, city, zip code)County6.PREMISES TELEPHONE NUMBER7.PREMISES ARE INSIDE CITY LIMITS8.BUSINESS NAME (DBA) YOU WILL USEYesNo9.BUSINESS MAILING ADDRESS (Street number and name, city, state, zip code)10.MAILING ADDRESSPermanentTemporary11.ABC LICENSE COST (Item #33a on reverse)12.SUBTOTAL (Item #33f on reverse)13.HAS THE APPLICANT(S) EVER BEEN14.HAS THE APPLICANT(S) EVER VIOLATED ANY OF THE PROVISIONS OF THE ALCOHOLIC BEVERAGE CONTROL ACT OR REGULATIONSCONVICTED OF A FELONY?OF THE DEPARTMENT PERTAINING TO THE ACT?YesNoYesNo15.IF YES TO ITEM 13 OR 14, PLEASE EXPLAIN16.TRANSFEROR'S NAME (If an individual, last, first, middle. Name of entity if corporation, limited partnership or limited liability company.)17.ABC LICENSE NUMBER18.TRANSFEROR'S PREMISES ADDRESS (Where license is now issued) (Street number and name, city, zip code)19.PREMISES UNDER CONSTRUCTIONIF YES, LIST ESTIMATED COMPLETION DATE20.FRANCHISEYesNoYesNo21.NAME OF PERSON WE MAY CONTACT (For the applicant)22.TITLE OF CONTACT PERSON23.CONTACT TELEPHONE NUMBER24.CONTACT E-MAIL ADDRESS25.PREMISES IS CURRENTLY LICENSEDIF YES, TYPE OF LICENSE26.CURRENT LICENSE IS OPERATINGIF NO, DATE CLOSEDYesNoYesNoFINANCIAL INFORMATION27.ESCROW COMPANY'S NAMEESCROW COMPANY'S ADDRESSTELEPHONE NUMBER28.BOOKKEEPER/ACCOUNTANT'S NAMEBOOKKEEPER/ACCOUNTANT'S ADDRESSTELEPHONE NUMBER29.LANDLORD'S NAMELANDLORD'S ADDRESSTELEPHONE NUMBER30.MONTHLY RENT31.LEASE EXPIRATION DATE32.INDICATE WHETHER LEASE OR RENTAL AGREEMENT INCLUDES FURNITURE OR FIXTURESAllSomeNoneABC-217 (rev. 11/11) State of California, Governor( ) ( ) ( )( ) ( ) American LegalNet, Inc. www.FormsWorkFlow.com COST a.ABC License$b.Furniture/fixtures$c.Inventory$$e.Leasehold and/or Improvements$$$h.Working capital (approximate)$i.Realty or interest therein$j.TOTAL INVESTMENT (Items f through i) (will equal total of amounts listed in item #33)$34.Source of Funds for Total Investment (item #33j) - identify amount(s), type(s) and explain source(s) and/or terms of RepaymentGiftJohn Doe, BrotherPromissory Noteto seller, payable @ $1,000 per month for 15 monthsLoanfrom ABC Bank, @ 8.5% over 5 yrs; monthly payment = $2,05235.LIST ALL BANK ACCOUNTS FOR THIS BUSINESS OPERATIONBANK NAMEBANK ADDRESSACCOUNT NUMBERa.b.c.NAMES OF ALL PERSONS AUTHORIZED TO SIGN ON BANK ACCOUNT(S) (Print)36.APPLICANT SIGNATURE (Only one signature needed)PRINTED NAMEDATE SIGNEDATTEST (ABC Employee or Notary Public)ABC-217 (rev. ) $15,000Source and/or Terms of RepaymentAmountType$1,000 $10,000 I understand that falsification of the information on this form may constitute grounds for denial or revocation of the license(s). For a period of 90 days from this date, I/we hereby authorize the Department of Alcoholic Beverage Control, or any of its officers, to examine and secure copies of financial records consisting of signature cards, checking and savings accounts, notes and loan documents, deposit and withdrawal records, and escrow documents of my/our financial institution(s) or any financial records established in connection with this business. This authorization to examine records at any financial institution may be revoked at any time. I/we also authorize the Department of Alcoholic Beverage Control, or any of its officers, to examine and secure copies of any business records or documents established in connection with this business including, but not limited to those on file with my/our bookkeeper. I/we also read all of the above and declare under penalty of perjury that each and every statement is true and correct. g.Fees for other licenses, permits, and deposits (approximate). Include Federal, State,County or City license fees or permits; lease and utility depositsd.Goodwill/non-competecovenant 33.INVESTMENT INFORMATION f.SUBTOTAL (Usually should equal the recorded notice) American LegalNet, Inc. www.FormsWorkFlow.com