Department of Alcoholic Beverage Control APPLICATION TO DETERMINEQUALIFICATIONS OF MANAGERLICENSE NUMBER RECEIPT NUMBER FEE $ PART I: To be completed by manager 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 APPLICANT NAME LICENSEE NAME PREMISES ADDRESS 1. Date assumed managerial duties at licensed premises?Yes No If Yes, list name and address of business(es) you managed: Dates of employment as manager at that location(s): 3.Do you have a written managerial agreement/contract? Yes No (If Yes, Attach Copy) 4. Salary? (Yearly / Monthly / Bi-weekly / Weekly / Percentage). 5. 6.Managerial duties:Hire & fire employees?Yes No Order new merchandise?Yes No Participate in policy decisions?Yes No Authority to write checks?Yes No Other applicable duties?Yes No 7.Are you replacing an already qualified manager at this premises?Yes No If Yes, prior manager's name: APPLICANT NAMEAPPLICANT SIGNATUREDATE SIGNEDPART II: To be completed by on-sale licenseeDATE OF EMPLOYMENT OR EXPECTED EMPLOYMENT LICENSEE MAILING ADDRESS (Street number and name, city, state, zip code)LICENSEE SIGNATURE ABC-405M (rev. 0/1) Commission or bonus? Yes No If Yes, gross or net? pursuant to Business and Professions Code Section 23788.5. ($100.00 fee) 2.Have you been previously qualified as a manager by the Department? State of California Governor 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 correc t. 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. American LegalNet, Inc. www.FormsWorkFlow.com