Department of Alcoholic Beverage Control State of California Edmund G. Brown Jr., Governor APPLICATION WITHDRAWAL To avoid delays with your refund, please be sure all information is completed. DATE OF WITHDRAWAL Read instructions on reverse before completing. PENDING FILE NUMBER 1. APPLICANT(S) NAME(S) 2. COPIES MAILED DATE 3. APPLICANT PREMISES ADDRESS (proposed premises) 4. LICENSE TYPE(S) APPLIED FOR 5. TRANSACTION TYPE Original Person to Person Transfer Exchange Other Premises Transfer 6. TRANSFEROR NAME (if applicable) 7. TRANSFEROR PREMISES ADDRESS (if applicable) 8. REASON FOR WITHDRAWAL 9. REFUND INFORMATION The undersigned hereby request the Department of Alcoholic Beverage Control to withdraw the above-described application and to refund or apply the fee as follows: Make refund payable to the applicant entity(s) as listed on Form ABC-211, Application for ABC License. Make refund payable to: I agree to submit documentation to ABC Headquarters within 15 days from the date I sign this withdrawal that the foregoing person paid the license fees. I understand that failure to submit documentation will result in the refund being made payable to the entity(s) shown on Form ABC-211, Application for ABC License. Apply fee on supplemental application for: 10. MAILING ADDRESS FOR REFUND (Street number and name, city, state, zip code) 11. APPLICANT SIGNATURE PRINTED NAME DATE SIGNED PRINTED NAME DATE SIGNED PRINTED NAME DATE SIGNED X 12. TRANSFEROR SIGNATURE (If applicable) X 13. SIGNATURE OF WITNESS X ABC USE ONLY If protested application, District Administrator/District Supervisor must complete this section. Investigation reveals: Application withdrawn due to protest. Applicant may not refile at this premises for one year (Section 24013.1 B&P Code). Application withdrawn due to protest against premises. Protests to remain valid at this premises for one year (Section 24013.2 B&P Code). Application not withdrawn due to the valid protest(s). Protests not to be carried forward. DISTRICT ADMINISTRATOR/DISTRICT SUPERVISOR SIGNATURE DATE SIGNED Original to HQ Licensing; copy to District files; if protested application, copy to HQ Hearing & Legal and Division Office. ABC-209 (rev. 01-11) American LegalNet, Inc. www.FormsWorkFlow.com