State of California Department of Alcoholic Beverage Control LICENSE TRANSFER REQUEST (“SIGN OFF”) • This form is to be signed by transferors only. • Read instructions before completing. • All signatures must be notarized in accordance with laws of the State where signed. 2. LICENSE NUMBER 1. DISTRICT OFFICE 3. TRANSACTION TYPE Exchange Person to Person Transfer 4. LICENSEE’S NAME (Transferor/Seller) Premise to Premise Transfer Other 5. APPLICANT’S NAME (transferee/Buyer) 6. EXISTING PREMISES ADDRESS 7. LICENSEE’S MAILING ADDRESS (Transferor/Seller) 8. LICENSEE’S PHONE NUMBER ( ) I hereby request surrender of my license under Section 24045.5(b) of the ABC Act so that a Temporary Permit may be issued to the transferee. 9. SIGNATURE OF TRANSFEROR/SELLER FOR TEMPORARY PERMIT(only one signature required) DATE SIGNED X 10. RENEWAL DUE DATE 11. SURRENDER DATE 12. TEMP. EFFECTIVE DATE 13. TEMP. EXPIRATION DATE TRANSFEROR’S CERTIFICATION Under penalty of perjury, each person whose signature appears below, certifies and says: (1) He is the licensee named in the foregoing transfer application, duly authorized to make this transfer application; (2) that he hereby makes application to surrender all interest in the license(s) described above and to transfer same to the applicant and/or location indicated on the upper portion of this form, if such transfer is approved by the Director; (3) that the transfer application or proposed transfer is not made to satisfy the payment of a loan or to fulfill an agreement entered into more than ninety days preceding the day on which the transfer application is filed with the Department or to gain or establish a preference to or for any creditor of transferor or to defraud or injure any creditor of transferor; (4) that the transfer application may be withdrawn by either the applicant or the licensee with no resulting liability to the Department. SOLE OWNER 14. SOLE OWNER’S PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED X PARTNERSHIP/LIMITED PARTNERSHIP (signatures of general partners only) SIGNATURE 15. PARTNER’S PRINTED NAME (Last, first, middle) DATE SIGNED X SIGNATURE PARTNER’S PRINTED NAME (Last, first, middle) DATE SIGNED X PARTNER’S PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED X CORPORATION 16. CORPORATE OFFICER’S PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED X TITLE President Vice President Chairman of the Board CORPORATE OFFICER’S PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED X TITLE Secretary Assistant Secretary Chief Financial Officer Assistant Treasurer LIMITED LIABILITY COMPANY Yes 17. The limited liability company is member-run No (If no, complete Item #18 below) 18. NAME OF DESIGNATED LLC MANAGER, MANAGING MEMBER OR DESIGNATED OFFICER (Last, first, middle) ABC INITIALS/DATE (ABC use only) 19. LLC MEMBER’S PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED LLC MEMBER’S PRINTED NAME (Last, first, middle) SIGNATURE X DATE SIGNED X ABC-211-A (9/01) "SIGN OFF" American LegalNet, Inc. www.FormsWorkflow.com State of California Department of Alcoholic Beverage Control LICENSE TRANSFER REQUEST LICENSE NUMBER TRANSFEROR’S CERTIFICATION Under penalty of perjury, each person whose signature appears below, certifies and says: (1) He is the licensee named in the foregoing transfer application, duly authorized to make this transfer application; (2) that he hereby makes application to surrender all interest in the license(s) described above and to transfer same to the applicant and/or location indicated on the upper portion of this form, if such transfer is approved by the Director; (3) that the transfer application or proposed transfer is not made to satisfy the payment of a loan or to fulfill an agreement entered into more than ninety days preceding the day on which the transfer application is filed with the Department or to gain or establish a preference to or for any creditor of transferor or to defraud or injure any creditor of transferor; (4) that the transfer application may be withdrawn by either the applicant or the licensee with no resulting liability to the Department. ADDITIONAL SIGNATURES 20. 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 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 PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED X PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED X ABC-211-A (9/01) (reverse) “SIGN OFF” American LegalNet, Inc. www.FormsWorkflow.com