INSTRUCTIONS FOR COMPLETING DBPR ABT – 6008 DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO APPLICATION FOR IMPORTERS, BROKERS, OR SALES AGENT LICENSES Application begins on page 4 If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation or your local district office. Please submit your completed application and required fee(s) to your local district office. This application may be submitted by mail, through appointment, or it can be dropped off. A District Office Address and Contact Information Sheet can be found on AB&T’s page of the DBPR web site at the link provided below. http://www.myflorida.com/dbpr/abt/district_offices/licensing.html GENERAL INSTRUCTIONS Submitting Your Application Please complete all information. All questions are applicable and must be answered fully and truthfully. You must provide an original and a copy of the application and duplicate copies of all supporting documentation. All signatures must be original. Note: When applicable, you must submit two legible and executed copies of your lease agreement. Florida law prohibits transfer applicants from assuming operation of a licensed establishment and selling alcoholic beverages prior to obtaining a temporary or permanent license in the transferee's name. APPLICATION REQUIREMENTS Affidavit of Applicant Read and sign in the presence of a notary. The affidavit must be signed by the individual applicant; all partners of a general partnership; all general partners of a limited partnership; all managing members of a limited liability company; or one of the officers of a corporate applicant. Affidavit of Transferor The affidavit of transferor must be completed for all transfer applications. The affidavit must be signed by the individual owner, all partners of a general partnership, all general partners of a limited partnership, all managing members of a limited liability company, or a corporate officer of record. If the transfer is pursuant to operation of law or judicial proceedings, certified copies of court order(s) in which the applicant is named may be accepted in lieu of signature(s) of seller. Fingerprints Fingerprints must be submitted by each individual applicant, all corporate officers, all managing members, all general partners of a limited partnership, all partners of a general partnership, each individual stockholder owning more than .5 percent of stock, and all directors. Each applicant shall submit electronic fingerprints through the department’s vendor PearsonVue. Costs associated with the fingerprint process will be collected by PearsonVue. You may contact PearsonVue at www.pearsonvue.com or by calling 1.888.274.2020. At the time application is made to the Division of Alcoholic Beverages and Tobacco, you will need to submit your PearsonVue receipt. The receipt serves as proof of the fingerprint requirement and includes information necessary to process your application. Failure to provide this receipt will delay the processing and/or denial of your application. Note: If you are a current licensee or have been fingerprinted by this division in the past three (3) years, you are not required to submit this fingerprint information. Partner, Officer, Stockholder Personal Data - Section 4 1 American LegalNet, Inc. www.FormsWorkflow.com This section of the application must be completed with original signatures for each applicant or person(s) directly connected with the business, unless they are current licensees. This will include the sole proprietor, all partners, officers, directors, individual share holders owning more than .5% of stock in nonpublic corporations, general partners of general partnerships, general partners of a limited partnership, and the managing partners of a limited liability company. Directly interested persons include anyone that is connected with the business who has a beneficial interest. It is important that each individual disclose any arrests they have had, even if they were charged, but not formally arrested, and regardless of the disposition. Corporate And Limited Partnership Registration All corporations, domestic or foreign; general partnerships; limited liability corporations; and limited partnerships are required to be registered with the Florida Secretary of State, Division of Corporations. If you have not already registered, you will need to contact the Department of State at (850) 488-9000 for further information. Your application cannot be accepted by this division without this registration. Federal Employer's Identification Number (FEIN) All licensees who pay wages to one or more employees must have a Federal Employer's Identification Number. Contact the Internal Revenue Service (IRS) at 1-800-829-3676 and request Form #SS4. Sketch of Premises A Florida location address is required; however, a sketch is not necessary if the Florida location is that of a resident agent. A sketch is required if the importers, brokers, or sales agent location is domiciled in Florida. If applicable, you must submit a legible and executed copy of your lease. Certified Copy of Arrest Disposition If the applicant answers “yes” to any of the criminal background questions asked in this application, provide a Certified Copy of the Arrest Disposition to ensure the applicant is qualified, pursuant to Statute and Rule. Mitigation for Moral Character If the applicant is required to submit an arrest disposition, they may also be required to submit mitigation under the moral character rule. A copy of the rule and requirements can be found on AB&T’s page of the DBPR web site. Disclosure of Interested Parties The applications must disclose all persons or entities having an interest, direct or indirect, in the business sought to be licensed and questions must be answered for each person or entity. 2 American LegalNet, Inc. www.FormsWorkflow.com APPLICATION CHECKLIST Select the appropriate transaction below and comply with the corresponding application requirements. TRANSACTION Initial License as Importer (IMPR) APPLICATION REQUIREMENTS Pay $125 fee if requesting an initial temporary license (make checks payable to the Department of Business and Professional Regulation) Complete DBPR ABT-6008 Division of Alcoholic Beverages and Tobacco Application for Importer or Broker Sales Agent Submit a certified copy of the disposition, if applicable Contact the department’s vendor for electronic fingerprinting, PearsonVue at www.pearsonvue.com or call 1.888.274.2020 to arrange for fingerprinting. Submit the receipt issued by PearsonVue with your application. Submit Secretary of State Certificate of Status Certified copy of the Arrest Disposition, if applicable Mitigation for Moral Character, if applicable Initial License as Broker Sales Agent (BSA) Pay $125 fee if requesting an initial temporary license (make checks payable to the Department of Business and Professional Regulation) Complete DBPR ABT-6008 Division of Alcoholic Beverages and Tobacco Application for Importer or Broker Sales Agent Submit a certified copy of the disposition, if applicable Contact the department’s vendor for electronic fingerprinting, PearsonVue at www.pearsonvue.com or call 1.888.274.2020 to arrange for fingerprinting. Submit the receipt issued by PearsonVue with your application. Submit Secretary of State Certificate of Status Transfer of Ownership Pay $100 fee if requesting an initial temporary license (make checks payable to the Department of Business and Professional Regulation) Complete DBPR ABT-6008 Division of Alcoholic Beverages and Tobacco Application for Importer or Broker Sales Agent Contact the department’s vendor for electronic fingerprinting, PearsonVue at www.pearsonvue.com or call 1.888.274.2020 to arrange for fingerprinting. Submit the receipt issued by PearsonVue with your application. Submit Secretary of State Certificate of Status 3 American LegalNet, Inc. www.FormsWorkflow.com DBPR ABT-6008 – Division of Alcoholic Beverages and Tobacco Application for Importer or Broker Sales Agent STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION NOTE – This form must be submitted as part of an application packet If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation or your local district office. Please submit your completed application and required fee(s) to your local district office. This application may be submitted by mail, through appointment, or it can be dropped off. A District Office Address and Contact Information Sheet can be found on AB&T’s page of the DBPR web site at the link provided below. http://www.myflorida.com/dbpr/abt/district_offices/licensing.html SECTION 1 - CHECK TRANSACTION REQUESTED Transaction Type: New License Do you wish to purchase a Temporary License? Yes No Transfer of Ownership Change of Location Change of Business Name Change of Officers/Stockholders Corporate Document Number SECTION 2 - CHECK LICENSE CATEGORY Importer Broker Sales Agent SECTION 3 - LICENSE INFORMATION Full Name of Applicant (If this is a corporation or other legal entity, enter the name as registered with the Secretary of State) Trade Name (D/B/A) Florida Location Address (Street and Number) City County State Zip Code State Zip Code Mailing Address (Street or P.O. Box) City FEIN Number Business Telephone Number 4 Current License Number, if applicable American LegalNet, Inc. www.FormsWorkflow.com SECTION 4 – PARTNER, OFFICER, STOCKHOLDER PERSONAL INFORMATION This section must be completed for each applicant or person(s) directly connected with the business, unless they are current licensees. 1. Trade Name (D/B/A) 2. Full Name of Applicant Social Security Number* Race Sex Home Phone Number Height Weight 3. Hair Color Are you a U.S. citizen? Yes No If no, immigration card number or passport number: 4. Eye Color Date of Birth Home Address (Street and Number) City 5. State Zip Code Do you currently own or have an interest in any business selling alcoholic beverages, wholesale cigarette or tobacco products, or a bottle club? Yes No If yes, provide the information requested below. The location address should include city and state. Trade Name (D/B/A) License Number Location Address 6. Have you ever had any type of alcoholic beverage, or bottle club license, or cigarette, or tobacco permit refused, revoked or suspended anywhere in the past 15 years? Yes No If yes, provide the information requested below. The location address should include the city and state. D/B/A Name Date Location Address 7. Have you been convicted of a felony or an offense involving alcoholic beverages anywhere? Yes No If yes, provide the information requested below and provide a Certified Copy of the Arrest Disposition, as requested in the Application Requirements checklist. Date Location Type of Offense 8. Have you ever been arrested or issued a notice to appear in any state of the United States or its territories? Yes No If yes, provide the information requested below and a CERTIFIED COPY OF THE DISPOSITION. Attach additional sheet if necessary. Date Location Type of Offense 5 American LegalNet, Inc. www.FormsWorkflow.com 9. Are you an official with State police powers granted by the Florida Legislature? Yes No If yes, provide details: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ _______________________________________________________________________________ NOTARIZATION STATEMENT “I swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791, 562.45 and 837.06, Florida Statutes, that I have fully disclosed any and all parties financially and or contractually interested in this business and that the parties are disclosed in Section 6 of this application. I further swear or affirm that the foregoing information is true and correct.” STATE OF___________________ COUNTY OF_________________ _________________________________________________ APPLICANT SIGNATURE The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this _______Day of______________, 20_____, By_____________________________________ who is ( ) personally known to me OR ( ) who produced ______________________________________________as identification. ________________________________________________ Commission Expires: ___________________ Notary Public (ATTACH ADDITIONAL COPIES AS NECESSARY) *Social Security Number Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless a Federal statute specifically requires it or allows states to collect the number. In this instance, disclosure of social security numbers is mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and sections 409.2577, 409.2598, and 559.79, Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and are used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec. 317. The State of Florida is authorized to collect the social security number of licensees pursuant to the Social Security Act, 42 U.S.C. 405(c)(2)(C)(I). This information is used to identify licensees for tax administration purposes. 6 American LegalNet, Inc. www.FormsWorkflow.com SECTION 5 – DESCRIPTION OF PREMISES TO BE LICENSED AB&T AUTHORIZED SIGNATURE REQUIRED Trade Name (D/B/A) 1. Yes No 2. Yes No 3. Is the proposed premises movable or able to be moved? Is there any access through the premises to any area over which you do not have dominion and control? Neatly draw a floor plan of the premises in ink, including sidewalks and other outside areas which are contiguous to the premises, walls, doors, counters, sales areas, storage areas, restrooms, bar locations and any other specific areas which are part of the premises sought to be licensed. A multi-story building where the entire building is to be licensed must show each floor plan. No architectural drawings are accepted. AB&T Authorized Signature___________________________________________ Date_________________ Approved Disapproved Comments_____________________________________________________________________________ ______________________________________________________________________________________ 7 American LegalNet, Inc. www.FormsWorkflow.com SECTION 6 – DISCLOSURE OF INTERESTED PARTIES Note: Failure to disclose an interest, direct or indirect, could result in denial, suspension and/or revocation of your license. Trade Name (D/B/A) 1. List below the name, title and address for all principals of the business. Attach extra sheets if necessary. NAME TITLE ADDRESS 2. Have you in the past or presently, individually or as an officer or stockholder of a corporation in this state or any other state: a. Held stock or had any interest in, affiliated or connected with, directly or indirectly, any Yes No business which sells any alcoholic beverages at retail? b. Held stock or had any interest in, affiliated or connected with, directly or indirectly, any business which manufactures, distributes, imports or exports any alcoholic Yes No beverages? If the answer to either of these questions is “yes”, list full particulars to include business names, cities, states, and dates. 8 American LegalNet, Inc. www.FormsWorkflow.com SECTION 7 - AFFIDAVIT OF APPLICANT NOTARIZATION REQUIRED Trade Name (D/B/A) "I, the undersigned individual, or if a corporation for itself, its officers and directors, hereby swear or affirm that I am duly authorized to make the above and foregoing application and, as such, hereby acknowledge that access must be provided to authorized employees of the division to all business premises and records. I swear under oath or affirmation under penalty of perjury as provided in Sections 559.791, 562.45 and 837.06, Florida Statutes, that the foregoing information is true and correct and that no other person or entity except as indicated herein has an interest in the business and that all of the above listed persons or entities meet the necessary qualifications to be licensed as an Importer, Broker, or Sales Agent." STATE OF___________________ _________________________________________________ APPLICANT SIGNATURE COUNTY OF_________________ _________________________________________________ APPLICANT SIGNATURE The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this ______ Day of______________, 20_____, By_________________________________ who is ( ) personally known to me OR ( ) who produced ______________________________________________as identification. ________________________________________________ Commission Expires: ___________________ Notary Public 9 American LegalNet, Inc. www.FormsWorkflow.com SECTION 8 - AFFIDAVIT OF TRANSFEROR NOTARIZATION REQUIRED Trade Name (D/B/A) "I, the undersigned, hereby swear or affirm that I am duly authorized to make this affidavit and do hereby consent, on my behalf or on behalf of the transferor, to the above transfer, and represent to the Division of Alcoholic Beverages and Tobacco that the license which is being transferred is as shown in the application and that a bona fide sale in good faith has been made to the within applicant of the business for which the foregoing transfer of license is sought." STATE OF___________________ _________________________________________________ TRANSFEROR OR AUTHORIZED OFFICER SIGNATURE COUNTY OF_________________ _________________________________________________ TRANSFEROR OR AUTHORIZED OFFICER SIGNATURE The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this ______ Day of______________, 20_____, By_________________________________ who is ( ) personally known to Me OR ( ) who produced ______________________________________________as identification. ________________________________________________ Commission Expires: ___________________ Notary Public FOR DIVISION USE ONLY Trade Name (D/B/A) ID Number 10 American LegalNet, Inc. www.FormsWorkflow.com