State of California Department of Alcoholic Beverage Control APPLICATION SIGNATURE SHEET ("SIGN ON") • This form is to be used as the signature page for applications not signed in the District Office. • Read instructions on reverse before completing. • All signatures must be notarized in accordance with laws of the State where signed. 1. OWNERSHIP TYPE (Check one) Sole Owner Partnership Partnership-Ltd Corporation 3. LICENSE TYPE Limited Liability Company Domestic Partner 2. FILE NUMBER (If any) Married Couple Other 4. TRANSACTION TYPE Original Person to Person Transfer Exchange Premise to Premise Transfer Other 5. APPLICANT(S) NAME (Last, first, middle) 6. APPLICANT'S MAILING ADDRESS (Street address/P.O. box, city, state, zip code) 7. PREMISES ADDRESS (Street address, city, zip code) APPLICANT'S CERTIFICATION Under penalty of perjury, each person whose signature appears below, certifies and says: (1) He/She is an applicant, or one of the applicants, or an executive officer of the applicant corporation, named in the foregoing application, duly authorized to make this application on its behalf; (2) that he/she has read the foregoing and knows the contents thereof and that each of the above statements therein made are true; (3) that no person other than the applicant or applicants has any direct or indirect interest in the applicant or applicant's business to be conducted under the license(s) for which this application is made; (4) that the transfer payment of a loan or to fulfill an agreement entered into more than ninety (90) days preceding the day on which the transfer application is filed with the Department, (b) to gain or establish a preference to or for any creditor or transferor, or (c ) to defraud or injure any creditor or transferor; (5) that the transfer application may be withdrawn by either the applicant or the licensee with no resulting liability to the Department. I understand that if I fail to qualify for the license or withdraw this application there will be a service charge of one-fourth of the license fee paid, up to $100. SOLE OWNER 8. PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED X PARTNERSHIP/LIMITED PARTNERSHIP (Signatures of general partners only) 9. PARTNER'S PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED X PARTNER'S PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED X PARTNER'S PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED X CORPORATION 10. PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED X TITLE President Vice President Chairman of the Board PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED X TITLE Secretary Asst. Secretary Chief Financial Officer Asst. Treasurer LIMITED LIABILITY COMPANY 11. The limited liability company is member-run Yes No (If no, complete Item #12 below) 12. NAME OF DESIGNATED MANAGER, MANAGING MEMBER OR DESIGNATED OFFICER (Last, first, middle) 13. MEMBER'S PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED X MEMBER'S PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED X ABC-211-SIG (2/09) "SIGN ON" American LegalNet, Inc. www.FormsWorkFlow.com State of California Department of Alcoholic Beverage Control APPLICATION SIGNATURE SHEET (continued) APPLICANT'S CERTIFICATION Under penalty of perjury, each person whose signature appears below, certifies and says: (1) He/She is an applicant, or one of the applicants, or an executive officer of the applicant corporation, named in the foregoing application, duly authorized to make this application on its behalf; (2) that he/she has read the foregoing and knows the contents thereof and that each of the above statements therein made are true; (3) that no person other than the applicant or applicants has any direct or indirect interest in the applicant or applicant's business to be conducted under the license(s) for which this application is made; (4) that the transfer payment of a loan or to fulfill an agreement entered into more than ninety (90) days preceding the day on which the transfer application is filed with the Department, (b) to gain or establish a preference to or for any creditor or transferor, or (c ) to defraud or injure any creditor or transferor; (5) that the transfer application may be withdrawn by either the applicant or the licensee with no resulting liability to the Department. I understand that if I fail to qualify for the license or withdraw this application there will be a service charge of one-fourth of the license fee paid, up to $100. ADDITIONAL SIGNATURES 14. PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED X PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED X PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED X PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED X PRINTED NAME (Last, first, middle) SIGNATURE PRINTED NAME (Last, first, middle) DATE SIGNED SIGNATURE X DATE SIGNED X PRINTED NAME (Last, first, middle) SIGNATURE PRINTED NAME (Last, first, middle) DATE SIGNED SIGNATURE X DATE SIGNED X PRINTED NAME (Last, first, middle) SIGNATURE PRINTED NAME (Last, first, middle) DATE SIGNED SIGNATURE X DATE SIGNED X INSTRUCTIONS AND GENERAL INFORMATION • Type or print clearly in black or blue ink (do not use red). • If you need more space for signatures, use Item #14. _______________ Ownership Type (Item #1) - Check the box for the type of ownership for the business. File Number (Item #2) - If this is an application for a transfer or exchange, enter the number assigned to the specific license being transferred or exchanged. License Type (Item #3) - Enter the numeric designation for the license (e.g., Type 21) or description (e.g., Off-Sale General). Transaction Type (Item #4) - Check the box for the type of transaction. Applicant(s) Name (Item #5) - Enter the name of the applicant. For a general partnership, the names of the individual partners. For a limited partnership, limited liability company, or a corporation, the name of the entity. Applicant's Mailing Address (Item #6) - Enter the address where you wish to receive mail. May be different from the premises address. Business and mailing addresses are public information and are available to the public. Please consider this, especially when listing a mailing address. ABC-211-SIG (2/09) Premises Address (Item #7) - Enter the location of the premises for which the license is applied. Partnerships (Item #9) - The application must be signed by each of the partners (e.g., general partnerships, husband and wife, etc.) Limited Partnerships - The application must be signed by each of the general partners. Limited partners do not need to sign. Corporations (Item #10) - The application must be signed by two officers of the corporation, one from each of the following categories: (a) The chairperson of the board, the president, or a vice president; and (b) the secretary, assistant secretary, chief financial officer, or assistant treasurer. Limited Liability Companies (Item #13) - For a limited liability company that is managed by its members, the application must be signed by each member or by an officer authorized by the articles of organization or the operating agreement to bind the company. For a limited liability company that is managed by a manager or managers, the application must be signed by the manager or managers or by an officer authorized by the articles of organization or the operating agreement to bind the company. "SIGN ON" American LegalNet, Inc. www.FormsWorkFlow.com