DR 8409 (06/05/07) COLORADO DEPARTMENT OF REVENUE LIQUOR ENFORCEMENT DIVISION 1375 SHERMAN STREET DENVER CO 80261 21 COLORADO LIQUOR OR 3.2% FERMENTED MALT BEVERAGE PUBLIC TRANSPORTATION, WHOLESALE, MANUFACTURER, IMPORTER LICENSE APPLICATION NEW LICENSE LICENSE RENEWAL TRANSFER OF OWNERSHIP • ALL ANSWERS MUST BE PRINTED IN BLACK INK OR TYPEWRITTEN • APPLICANT MUST CHECK THE APPROPRIATE BOX(ES) • APPLICANT SHOULD OBTAIN A COPY OF THE COLORADO LIQUOR AND BEER CODE (Call 303-370-2165) 1a. Applicant is applying as a DO NOT WRITE IN THIS SPACE Individual (Attach DR 8404-I) Corporation Limited Liability Company Partnership (Includes Limited Liability and Husband and Wife Partnerships) Association or Other 1b. Name of Applicant(s) If partnership, list partners' names (at least two); if corporation, name of corporation FEIN Number 2. Trade Name of Establishment (DBA) Business Telephone State Sales Tax No. 3. Address of Premises (specify exact location of premises) City County State ZIP Code 4. Mailing Address (Number and Street) City or Town State ZIP Code 5. If the premises currently have a liquor or beer license, you MUST answer the following questions: Present State License No. Present Class of License Present Expiration Date Present Trade Name of Establishment (DBA) LIAB SECTION A LIAB 2300 2310 Application Fee for New License ............... $1,025.00 Application Fee for Transfer of Ownership .. 1,025.00 2000 LIQUOR LICENSE FEES SECTION D Public Transportation License $75.00 x (# Units) Total Fee 2080 SECTION B 2130 3.2% Beer Wholesale License ..................... 150.00 2140 3.2% Beer Manufacturer's License .............. 150.00 2160 3.2% Beer Importer's License ...................... 150.00 2150 3.2% Nonresident Manufacturer License ..... 150.00 Manufacturer's License (brewery) ...................... 300.00 2100 Manufacturer's License (winery) ........................ 300.00 2090 Manufacturer's License (distillery or rectifier) .. 1,050.00 2050 Wholesale Liquor License (vinous & spirituous) ....................................... 1,050.00 2240 Sole Source Registration $100.00 X_____ ... Total Fee_____ 2290 Product Registration $5.00 X_____ ... Total Fee_____ 2060 Wholesale Beer License (malt liquor) ................ 550.00 1920 SECTION C Importer's License (malt liquor) .......................... 300.00 2070 Importer's License (vinous & spirituous liquor) ... 300.00 1930 Limited Winery License ........................................ 70.00 1910 Nonresident Manufacturer's License (malt liquor) ........................................................ 300.00 DO NOT WRITE IN THIS SPACE - FOR DEPARTMENT OF REVENUE USE ONLY LIABILITY INFORMATION Liability Date State Cash Fund New License (999) 2300-100 (999) License Issued Through (Expiration Date) FEE PAID FOR BEER, WINE, AND SPIRITUOUS LIQUOR Cash Fund Sole Source Product Transfer License Registration Registration 2310-100 (999) 2240-100 (999) 2290-100 (999) License Account Number TOTAL American LegalNet, Inc. www.FormsWorkflow.com DR 8409 (06/05/07) Page 2 APPLICATION CHECKLIST AND WORKSHEET Instructions: This check list should be utilized to assist applicants with filing all documents required for licensure. All documents must be properly signed and correspond with the name of the applicant exactly. Copies (other than application) may be accepted if signatures are legible. All documents must be typed or legibly printed in black ink. Upon state approval, the license will be mailed to you. ITEMS SUBMITTED DOCUMENTS PLEASE CHECK ALL APPROPRIATE BOXES I. APPLICANT INFORMATION A. Identify Applicant/Licensee. B. Identify license type or other transaction. C. Identify State Sales Tax License Number (Transportation applicant only). D. Submit original application. II. DIAGRAM (WHOLESALERS, TRANSPORTATION AND INSTATE MANUFACTURERS) A. 8 1/2" X 11" diagram of property to be licensed. B. Address and diagram of premises where liquor is to be stored (Transportation and wholesale applicants only). III. PROOF OF PROPERTY POSSESSION (NOT REQUIRED FOR IMPORTERS AND NON RESIDENT MANUFACTURERS) A. Deed in name of the Applicant ONLY (or) B. Lease in the name of the Applicant ONLY and valid for at least one (1) year from the date of license issuance, or C. Lease Assignment in the name of the Applicant ONLY with proper consent from the Landlord and acceptance by the Applicant. D. Copy of Vehicle Registration (Transportation applicant only). E. Copy of Vehicle Lease (Transportation applicant only). F. Other Agreement if applicable. IV. BACKGROUND INFORMATION (DR 8404-I) A. Complete for each principal (stockholder, officer, director, partner, member, etc.). B. Complete fingerprint cards for the same persons mentioned in "A" above. Cards are to be taken to the local police department for fingerprinting. Return the completed cards to this department with a check for $ ________________ , per card, made payable to COLORADO BUREAU OF INVESTIGATION. V. CORPORATE APPLICANT INFORMATION (If Applicable) A. Certificate of Incorporation (and/or) B. Certificate of Good Standing if incorporated more than two years old. C. Certificate of Authorization if foreign corporation (instate applicant's only). D. List of officers, directors and stockholders of any PARENT corporation (designate one person as "principal officer"). VI. PARTNERSHIP APPLICANT INFORMATION (If Applicable) VII. LIMITED LIABILITY COMPANY APPLICANT INFORMATION (If Applicable) A. Copy of articles of organization (date stamped by Colorado Secretary of State's Office). B. Copy of operating agreement. C. Certificate of Authority, if foreign company (instate applicant's only). VIII. OTHER PERMITS A. Copies of all Federal Basic Permits. B. Copy of Colorado PUC authority (Transportation applicants only). IX. PRODUCT INFORMATION A. IMPORTERS AND NONRESIDENT MANUFACTURERS 1. See PROCESSING DOCUMENT FOR ADDITIONAL FEES. 2. Sole Source of Supply/Brand Registration (DR 8440). 3. Copy of Geographic Territory Agreement (beer importers only): a properly executed and binding agreement showing, for each wholesaler, the designated products to be sold and territories assigned for product distribution. 4. Copies of federal brand label approvals. 5. If applicant is not the U.S. Primary Source, a letter of appointment from primary source. B. WHOLESALERS 1. Disclose your Colorado licensed importer. 2. Copy of Geographic Territory Agreement (Beer only): a properly executed and binding agreement from the Colorado licensed manufacturer or importer showing the designated products being sold and territories for product distribution. C. INSTATE MANUFACTURERS 1. If not submitting labels for federal approval, submit labels for state approval. X. APPLICATION REVIEW A. Complete in all sections. B. Sign application. A. Partnership Agreement (general or limited). Not needed if husband and wife. American LegalNet, Inc. www.FormsWorkflow.com DR 8409 (06/05/07) Page 3 6. Is the applicant (including any of the partners, if a partnership; members or manager if a limited liability company; or officers, stockhold- Yes No ers or directors if a corporation) or manager under the age of twenty-one years? 7. Has the applicant (including any of the partners, if a partnership; members or manager if a limited liability company; or officers, stockholders or directors if a corporation) or manager ever (in Colorado or any other state); (a) been denied an alcoholic beverage license? (b) had an alcoholic beverage license suspended or revoked? (c) had interest in another entity that had an alcoholic beverage license suspended or revoked? If you answered yes to 7a, b or c, explain in detail on a separate sheet. 8. Has a liquor or beer license ever been issued to the applicant (including any of the partners, if a partnership; members or manager if a limited liability company; or officers, stockholders or directors if a corporation)? If yes, identify the name of the business and list any current financial interest in said business including any loans to or from a licensee. 9. Does the Applicant, as listed on line 1b of this application, have legal possession of the premises for at least 1 year from the date that this license will be issued by virtue of ownership, lease, or other arrangement? Ownership Lease Other (Explain in Detail) ___________________________________________________________________ a. If leased, list name of landlord, tenant, and date of expiration EXACTLY as they appear on the lease: Landlord 10. Tenant Expires Who, beside the owners listed in this application (including persons, firms, partnerships, corporations, limited liability companies), will loan or give money, inventory, furniture or equipment to or for use in this business; who will receive money from this business? Attach a separate sheet if necessary. NAME DATE OF BIRTH FEIN OR SSN INTEREST Attach copies of all notes and security instruments, and any written agreement or details of any oral agreement, by which any person (including partnerships, corporations, limited liability companies, etc.) will share in the profit or gross proceeds of this establishment, and any agreement relating to the business which is contingent or conditional in any way by volume, profit, sales, giving of advice or consultation. 11. If applicant is a corporation, partnership, association or a limited liability company, it is required to list all officers and directors, general partners, managing members and all stockholders, partners (including limited partner) and members who have a 10% or greater financial interest in the applicant. All persons listed here or by attachment must submit a DR 8404-I (Individual History Record) and provide fingerprint cards to the state licensing authority. If a report of changes, then only provide background information for persons checked or new. NAME DATE OF BIRTH HOME ADDRESS, CITY & STATE POSITION % OWNED Additional Documents to be submitted by type of entity CORPORATION Cert. of Incorp. PARTNERSHIP Partnership Agreement (General or Limited) LIMITED LIABILITY COMPANY ASSOCIATION OR OTHER Registered Agent (if applicable) Cert. of Good Standing (if more than 2 yrs. old) Articles of Organization Cert. of Auth. (if a foreign corp.) Husband and Wife partnerships Cert. of Authority (if foreign company) Operating Agrmt. Attach copy of agreements creating association or relationship between the parties Address for Service American LegalNet, Inc. www.FormsWorkflow.com DR 8409 (06/05/07) Page 4 12. Colorado Manufacturer, Wholesaler or Limited Winery applicants, answer the following: (a) Will the applicant store or sell alcoholic beverages at more than one location in Colorado? If yes, provide the address of each location and explain the activity to be conducted at each location (e.g., warehouse, salesroom, etc.). (b) If applicant is a wholesaler, does or did any owner, partner, shareholder, director, officer, member or manager have any direct or indirect financial interest in a wholesaler, retailer, manufacturer or importer already licensed by the State of Colorado to sell malt, vinous or spirituous liquor? If yes, attach explanation in detail. (c) Does the applicant have a valid Federal Basic Permit or Brewers Notice? If yes, attach a copy; if no, explain whether one has been applied for. 13. Nonresident Manufacturer (3.2% beer or malt liquor) or Importer (3.2% beer, malt, vinous or spirituous liquor) applicants, answer the following: (a) To what Colorado licensed wholesaler do you intend to ship your merchandise? (b) Does or did any owner, partner, shareholder, director, officer, member or manager have any direct or indirect financial interest in a wholesaler, retailer, manufacturer or importer already licensed by the State of Colorado to sell malt, vinous or spirituous liquor? If yes, attach explanation in detail. (c) Does the applicant have a valid Federal Basic Permit or Brewers Notice? If yes, attach a copy; if no, explain in detail. (d) Are you the primary source of supply in the U.S.? If no, explain. (e) Are all your products registered in Colorado? If no, attach DR 8440 and register said products. 14. Public Transportation System license applicants, answer the following: (a) How many vehicles; cars, buses, planes or other conveyances ("units") will serve alcoholic beverages in Colorado? __________________ (b) Does the applicant have possession by title or lease of all of the units described above? (c) Does applicant have PUC authority? (attach copy of authority) (d) Where will liquor be stored? (list address) Yes No ______________________________________________________________ ______________________________________________________________ OATH OF APPLICANT I declare under penalty of perjury in the second degree that this application and all attachments are true, correct, and complete to the best of my knowledge. I also acknowledge that it is my responsibility and the responsibility of my agents and employees to comply with the provisions of the Colorado Liquor or Beer Code which affect my license. Authorized Signature Title Date REPORT AND APPROVAL BY STATE LICENSING AUTHORITY Yes No Each person required to file DR 8404-I a. Has been fingerprinted b. Background and NCIC and CCIC check for outstanding warrants conducted For Wholesalers and Manufacturers only The liquor licensed premises has been inspected by an agent of the State Licensing Authority. If "no", the building will be completed and ready for inspection by (date) By Title Date American LegalNet, Inc. www.FormsWorkflow.com