State of California Department of Alcoholic Beverage Control 1. OWNERSHIP TYPE (Check one) 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. 2. FILE NUMBER (If any) 3. LICENSE TYPE Sole Owner Partnership Married Couple Domestic Partner 4. TRANSACTION TYPE Partnership-Ltd Corporation Limited Liability Company Other Person to Person Transfer Premise to Premise Transfer Other Original Exchange 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 SOLE OWNER 8. PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED 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or transferor, or (c ) to defraud or injure any creditor or transferor; (5) that the transfer application may be withdrawn by either the applicant or the licensee with no resulting liability to the Department.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. 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 SIGNATURE DATE SIGNED PRINTED NAME (Last, first, middle) 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 14. PRINTED NAME (Last, first, middle) SIGNATURE 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. DATE SIGNED ADDITIONAL SIGNATURES 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 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 DATE SIGNED X PRINTED NAME (Last, first, middle) SIGNATURE 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) "SIGN ON" 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