State of California Edmund G. Brown Jr., Governor Department of Alcoholic Beverage Control APPLICATION TO DETERMINE QUALIFICATIONS OF MANAGER/LESSEE LICENSE NUMBER RECEIPT NUMBER FEE $ PART I: To be completed by manager/lessee I hereby request the Department of Alcoholic Beverage Control to determine my qualifications as: Manager of the on-sale licensed premises designated below, as provided by Rule 57.6 of the Department's Regulations and pursuant to Business and Professions Code Section 23788.5. ($100.00 fee) Lessee of the restaurant portion of the on-sale licensed premises designated below, as provided by Rule 57.7 of the Department's Regulations and pursuant to Business and Professions Code Section 23787. 1. APPLICANT NAME 2. PREMISES LICENSEE NAME Where employed or To be employed as manager PREMISES ADDRESS (Street number and name, city, zip code) Where leased APPLICANT MAILING ADDRESS (Street number and name, city, state, zip code) or Where will be leased 3. Have you ever been manager or lessee of a licensed premises against which disciplinary action has been taken by the Department during course of said employment or lease? Yes No 4. Explain YES answer I declare under penalty of perjury that I am the applicant named in the foregoing application, that I have read the foregoing application and know the contents thereof, and that each and every statement made and answer given therein is true and correct. APPLICANT SIGNATURE DATE SIGNED PART II: To be completed by on-sale licensee The facts concerning the employment as manager of the above-listed applicant are true as indicated. I further agree that I will promptly provide a copy of any written agreement or letter that may exist pertaining to the manager's duties, responsibilities and/or amount and manner of compensation and further will notify the Department upon the termination of applicant's employment as manager or transfer to another premises. The restaurant portion of the on-sale premises licensed as indicated above (will be leased) (has been leased to the above applicant. I further acknowledge that, as licensee, I am responsible for the sale/service of alcoholic beverages and any violations of the Alcoholic Beverage Control Act that may occur on said leased portion of the premises. I agree to promptly notify the Department upon termination of said lease. DATE OF EMPLOYMENT, EXPECTED EMPLOYMENT OR EFFECTIVE DATE OF LEASE LICENSEE MAILING ADDRESS (Street number and name, city, state, zip code) LICENSEE SIGNATURE ABC-405 (rev. 01-11) American LegalNet, Inc. www.FormsWorkFlow.com