ALCOHOLIC BEVERAGE CONTROL (ABC) LICENSE APPLICATION INSTRUCTIONS n ABC manager is required to be on duty and on the premises during the approvedlicensed hours of sales in order for the establishment to sell and serve alcoholic beverages. ABC manager arerequired to complete alcoholawareness trainingprogram offered by anBoard-approvedproviderThis program educates applicants onmatters related to thesale and consumption of alcoholertification valid for two years.FEES The application must be accompanied by the proper liceperiod from your issuance date. APPLICATION application designates the person in whose name the license will be issued if the application is approved. An applicant that wants to designate another individual to pick up the license must submit a written authorization to ABRA. An applicant must be at least 21 years of age and provide a valid government issued form of identification. Applications with ABRA must be submitted in person at: OTHER FORMS REQUIRED Personal Information Release AuthorizationClean Hands CertificationPolice ClearanceCourt DispositionAlcohol Awareness Certificate American LegalNet, Inc. www.FormsWorkFlow.com 8.b.c. a.U.S. Passport U.S. Certificate of Naturalization or CitizenshipPermanent Resident Card (Green Card) License Number: Date Accepted: Accepted by: Fees Paid: $ From To Issue Date: From To Date Approved by Board / / Date Denied by Board / / Initial TO BE COMPLETED BY APPLICANT e (Last, First, Middle Initial) 2.Date of Birth 3.Place of Birth 4.Personal Telephone Number 5.Residential Address City State Zip Code 6.Email address 7.Are you eligible to work in the United States? If yes, please bring qualifying documents and provide the information below: d. Work Permit e.Visa f.Certificate number g.Expiration date Have you ever:Received or applied for any alcoholic beverage license in D.C. or any state or territory b.Had any alcoholic beverage license suspended or revoked c.Been convicted of a misdemeanor during the last five (5) years or a felony during the last () years (If yes, attach a copy of the court dispositon(s)) Check appropriate box if any of the following apply:You have operational control over an ABC establishmentServe in a managerial capacity for an ABC establishmentThe establishment is owned by you or an immediate family member. 11.If you have answered yes to question 9 or 10 please a detailed explanation. 12.CertificationI, , hereby certify that I have obtained and read Title 25 of the D.C. Official Code and Title 23 of the District of Columbia Municipal Regulations. I understand that I will be held responsible for complying with the laws and regulations contained therein. I, certify under penalty of perjury, that the statements in the foregoing are true and correct. Subscribed and sworn to before me My commission Signature on this day of, 20. Notary Public expires on 13.In what language do you need vital documents translated? American LegalNet, Inc. www.FormsWorkFlow.com PERSONAL INFORMATION RELEASE AUTHORIZATION CAREFULLY READ THIS AUTHORIZATION TO RELEASE INFORMATION ABOUT YOU, THEN SIGN AND DATE IN INK. I authorize any agent from the Alcoholic Beverage Regulation Administration to obtain any information relating to my activities from employers, criminal justice agencies, financial or lending institutions, credit bureaus, consumer reporting agencies and retail business establishments, or individuals. This information may include, but is not limited to, my residential, personal, or criminal history record and financial and credit information. I further authorize release of my criminal history from criminal justice agencies for the purposes of determining my eligibility for a liquor license as either a licensee and/or investor. I understand that the information released is for official use by the Alcoholic Beverage Regulation Administration, and that these users may re-disclose this information as authorized by law. I release any individual, including records custodians, from all liability for damages that may result to me because of compliance, or any attempts to comply, with this authorization.This release is binding, now and in the future, on my heirs, assignees, associates and personal representative(s) of any nature. Copies of the authorization that show my signature are as valid as the original release signed by me. Failure to complete this form may result in delays of obtaining your license and may result in the license being denied if this information cannot otherwise be obtained. Signature Social Security Number Full Name (Print or type) Other Names Used(Print or type) Current Address Home Telephone Number Date I hereby certify under penalty of perjury that the foregoing information is true and correct. I further, hereby, authorize the Alcoholic Beverage Control Board or its employees to investigate any and all of the information provided by me in this application for an ABC License. Subscribed and sworn to before me My commission S ignature on this day of, 20. Notary Public expires on . American LegalNet, Inc. www.FormsWorkFlow.com CLEAN HANDS CERTIFICATION PLEASE READ CAREFULLY AND COMPLETELY BEFORE SIGNING. A FALSE STATEMENT ON THIS CERTIFICATION REQUIRES THAT THE ADMINISTRATION PROCEED IMMEDIATELY TO REVOKE THE LICENSE OR PERMIT FOR WHICH YOU ARE NOW APPLYING, AND FINE YOU $1,000.00. THIS CERTIFICATION IS REQUIRED BY THE CLEAN HANDS ACT OF 1996; EFFECTIVE MAY 11, 1996, (D.C. LAW 11-118, D.C. OFFICIAL CODE SEC. 47-2861 et seq.)BEFOREYOUARE ELIGIBLETO RECEIVE A LICENSE OR PERMIT. , , (Name residing at , with Social Security Number (Home Address) certify that as of this date, do not owe more than $100.00 to the District of Columbia Government as a result of: 1.Fines, penalties or interest assessed pursuant to the Litter Control Administrative Act of 1985, effective March 25,1986 (D.C. Law 6-100; D.C. Official Code Sec. 8-801 et seq.);2.Fines, penalties or interest assessed pursuant to the illegal Dumping Enforcement Act of 1994, effective May 20,1994 (D.C. Law 10-117; D.C. Official Code Sec. 8-901 et seq.);3.Fines, penalties or interest assessed pursuant to the Department of Consumer & Regulatory Affairs Civil InfractionAct of 1985, effective October 5, 1985 (D.C. Law 6-42; D.C. Official Code Sec. 2-1801.01 et seq.); or4.Past due taxes;5.Past due District of Columbia Water and Sewer Authority Service Fees;6.Traffic adjudication fines or penalties;7.Parking fines or penalties assessed by other jurisdictions, provided, that a reciprocity agreement is in effect betweenthe jurisdiction and the District;8.Fines assessed to car dealers; and9.Fines assessed pursuant to the Taxicab and Limousine Commission Establishment Amendment Act of 2004. I understand that if I knowingly falsify this Certification, the Administration will move to revoke the license or permit for which I am applying and fine me $1,000.00. I further understand that the Administration may conduct an investigation to ascertain the veracity of this Certification. I understand that this Certification is required as documentation to accompany my application for a license or permit, and that by completing this Certification, I am not guaranteed that my license or permit will be approved. Signature Print Name/Title ABC Application Number ABC License Number FOR OFFICIAL USE ONLY OFFICE OF TAX & REVENUE (OTR) SIGNATURE DATE American LegalNet, Inc. www.FormsWorkFlow.com