INSTRUCTIONS FOR COMPLETING DBPR ABT – 6004 DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO CHANGE TO LICENSED ENTITY APPLICATION 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 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 Applications for changes to related parties and/or licensed legal entities are filed with the Department of Business and Professional Regulation. Please complete all information. All questions are applicable and must be answered fully and truthfully. You must provide an original application and supporting documentation. All signatures must be original. You must provide an original application and supporting documentation. All signatures must be original. Note: When applicable, you must submit a legible and executed copy of the following: Purchase Agreements, Franchise Agreements, Management Contracts, Service Agreements, and any agreements which require a percentage payment from the business operation, Certified Copy of Death Certificate, Letters of Administration, Certificate of Title, Certified Copy of All Court Orders pertaining to the alcoholic beverage license. Contact Person All communications regarding your application will be sent to the applicant at the mailing address provided. If you would like us to communicate with someone other than the applicant, please provide the information for that person in the section labeled “License Information”. If you have appointed a person to act on your behalf and make changes to the application paperwork, please provide a copy of the Power of Attorney indicating such person is authorized to make changes on your behalf. If you have appointed an attorney to act on your behalf and make changes to the application paperwork, please provide a copy of the letter of representation. APPLICATION REQUIREMENTS Affidavit of Applicant Read and sign in the presence of a notary. The affidavit must be signed by the individual applicant, a partner of each general partnership, a general partner of each general partnership of a limited partnership, a managing member or manager of a limited liability company, or one of the officers of a corporate applicant. Fingerprints Fingerprints must be submitted by each sole proprietor, all partners, officers, directors, individual share holders owning more than ½ of 1 percent of stock in non-public corporations, general partners of general partnerships, general partners of a limited partnership, managing members or managers of a limited liability company, and persons directly interested and receiving financial proceeds from the business. Applicants must use a Livescan vendor that has been approved by the Florida Department of Law Enforcement to submit their fingerprints to the department. Costs associated with the fingerprint process will be collected by the vendor. . Vendor options and contact information can be viewed at our Fingerprint Frequently Asked Questions link below: (http://www.myfloridalicense.com/dbpr/servop/testing/documents/finger_faq.pdf). Please ensure that the Originating Agency Identification (ORI) number for the Division of Alcoholic Beverages and Tobacco is provided to the vendor when you submit your fingerprints. The ORI number is FL920150Z. If you do not provide the ORI number, or if you provide an incorrect ORI number to the vendor, the Department of Business and Professional Regulation will not receive your fingerprint results. Auth. 61A-5.0014, FAC 1 American LegalNet, Inc. www.FormsWorkFlow.com Out of state applicants must be fingerprinted by a law enforcement agency on cards provided by the division (note: law enforcement agencies may charge for this service). The Division of Alcoholic Beverages and Tobacco has a unique ORI number that is required for processing the fingerprints back to the division, therefore, you must contact one of our offices to make a request for a card to be mailed to you. You will need to enclose a money order (personal checks are not accepted) for the total amount of the cost associated with the fingerprint process, payable to Pearson VUE, with your card. You may contact Pearson VUE at www.pearsonvue.com or by calling 1.877.238.8232. Once you have been fingerprinted and all information is complete, mail the card to Pearson VUE at: FLDBPR, c/o Pearson VUE, Florida Fingerprinting Program, 3131 South Vaughn Way, Suite 205, Aurora, CO 80014 At the time application is made to the Division of Alcoholic Beverages and Tobacco, you will need to submit your fingerprint receipt. The receipt serves as proof that you have met the fingerprint requirement. Failure to provide this receipt will delay the issuance of your temporary or permanent license, and could result in your application being denied. Applications must be submitted within 150 days of the date fingerprints are taken. Note: If you are a current licensee you are not required to submit a new set of fingerprints with your application unless you have been arrested since your prior submission of fingerprints to the division. If you are not a current licensee but have been fingerprinted for this division in the past three (3) years, and you have not been arrested since that time, you are not required to submit new fingerprints unless the prior application was withdrawn or non-consummated. Related Party Personal Information 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 ½ of 1 percent of stock in non-public corporations, all partners of each general partnership, all general partners of a limited partnership, all managing members or managers of a limited liability company, and persons directly interested and receiving financial proceeds from the business. It is important that each individual discloses any arrests they have had within the past 15 years, even if they were charged, but not formally arrested, and regardless of the disposition. Copy of Arrest Disposition If the applicant answers “yes” to any of the criminal background questions asked in this application, provide a 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. Direct Interest A direct interest is a person or entity having an interest with the applicant in the business sought to be licensed and, includes but is not limited to: 1. an interest which is created by virtue of the interested party deriving revenue from the license; 2. a person or entity having the right to receive revenue based on a contractual relationship related to the control of the sale of alcoholic beverages, the terms of which, are contrary to 561.17, Florida Statutes, or 61A-3.017, Florida Administrative Code; 3. a person or entity who has a right to a percentage payment from the proceeds of the business, either by lease or otherwise. A direct interest does not include any person that derives revenue from the license solely through a contractual relationship with the licensee, the substance of which is not related to the control of the sale of alcoholic beverages, or is specifically exempt by statute or rule. Department of Revenue Clearance This clearance is only required if you have changes to the licensed entity name through the Florida Department of State, Division of Corporations. Applications must be submitted within 90 days of receiving this approval. Auth. 61A-5.0014, FAC 2 American LegalNet, Inc. www.FormsWorkFlow.com 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. Registration of Legal Entity All corporations, domestic or foreign; general partnerships; limited liability companies; and limited partnerships are required to be registered with the Florida Department of State, Division of Corporations. If you have not already registered, you will need to contact the Department of State at (850) 488-9000 or www.sunbiz.org for further information. Your application will be considered incomplete without this active 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. Applicant Entity Felony Conviction This question only applies if the legal entity is registered with Florida Department of State, Division of Corporations. If the answer is “yes”, list specific details. APPLICATION CHECKLIST TRANSACTION Change to Licensed Entity Change to Related Parties Auth. 61A-5.0014, FAC APPLICATION REQUIREMENTS Complete DBPR ABT-6004 Division of Alcoholic Beverages and Tobacco Change to Licensed Entity Application. Complete DBPR ABT-6004 Division of Alcoholic Beverages and Tobacco Change to Licensed Entity Application. Submit fingerprint receipt, if applicable. Copy of the Arrest Disposition, if applicable. 3 American LegalNet, Inc. www.FormsWorkFlow.com DBPR ABT-6004 – Division of Alcoholic Beverages and Tobacco Change to Licensed Entity Application STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION DBPR Form ABT-6004 Revised 09/2010 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 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: Change to Related Parties Amendment to Licensed Entity Name Conversion or Merger Change of Mailing Address Department of State Document # SECTION 2 – LICENSE INFORMATION FEIN # Full Name of Applicant: (This is the name the license will be issued in) Contact Person Phone Number E-Mail Address Mailing Address City State Zip Code Is this change due to a revocation proceeding? Yes No If yes, is there any personal relationship to any of the former related parties? Yes No If yes, explain the relationship: ABT District Office Received / Date Stamp Auth. 61A-5.0014, FAC 4 American LegalNet, Inc. www.FormsWorkFlow.com SECTION 3 – RELATED PARTY PERSONAL INFORMATION This section must be completed for each person directly connected with the business, unless they are a current licensee. 1. Full Name of Applicant 2. Full Name of Individual Social Security Number* - Race Sex Home Telephone Number Weight Eye Color Height 3. Are you a U.S. citizen? Yes No If no, immigration card number or passport number: 4. Date of Birth / / Hair Color 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 the city and state. Business Name (D/B/A) License Number Location Address 6. Have you 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. Business Name (D/B/A) Date Location Address 7. Have you been convicted of a felony within the past 15 years? Yes No If yes, provide the information requested below and provide a Copy of the Arrest Disposition, as requested in the Application Requirements checklist. Date Location Type of Offense Have you been convicted of an offense involving alcoholic beverages anywhere within the past 5 Yes No years? If yes, provide the information requested below and provide a Copy of the Arrest Disposition, as requested in the Application Requirements checklist. Date Location Type of Offense Auth. 61A-5.0014, FAC 5 American LegalNet, Inc. www.FormsWorkFlow.com 8. Have you been arrested or issued a notice to appear in any state of the United States or its territories Yes No within the past 15 years? If yes, provide the information requested below and a Copy of the Arrest Disposition. Attach additional sheet if necessary. Date Location Type of Offense 9. Are you an official with State police powers granted by the Florida Legislature? Yes No 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 the Disclosure of Interested Parties 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 (print name of person making statement) 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. Auth. 61A-5.0014, FAC 6 American LegalNet, Inc. www.FormsWorkFlow.com SECTION 4 – SALES TAX TO BE COMPLETED BY THE DEPARTMENT OF REVENUE Full Name of Applicant The named applicant for a license/permit has complied with the Florida Statutes concerning registration for Sales and Use Tax. 1. This is to verify that the current owner as named in this application has filed all returns and that all outstanding billings and returns appear to have been paid through the period ending ___________________ or the liability has been acknowledged and agreed to be paid by the applicant. This verification does not constitute a certificate as contained in Section 212.10 (1), F.S. (Not applicable if no transfer involved). 2. Furthermore, the named applicant for an Alcoholic Beverage License has complied with Florida Statutes concerning registration for Sales and Use Tax, and has paid any applicable taxes due. Signed____________________________________________________Date_____________________ Title______________________________________________________ Department of Revenue Stamp: SECTION 5 – CONTRACTS OR AGREEMENTS These questions must be answered about this business for every person or entity listed as the applicant and copies of agreements must be submitted with this application. If the management, service, or other contractual agreement gives a person or entity control of the licensed premises or the sale of alcoholic beverages, disclosure of those persons must be made in the section labeled “DIRECT INTEREST” in the DISCLOSURE OF INTERESTED PARTIES section. They must also submit fingerprints and a related party personal information sheet. 1. Yes No Is there a management contract, franchise agreement, or service agreement in connection with this business? 2. Yes No Are there any agreements which require a payment of a percentage of gross or net receipts from the business operation? 3. Yes No Have you or anyone listed on this application, accepted money, equipment or anything of value in connection with this business from a manufacturer or wholesaler of alcoholic beverages? Auth. 61A-5.0014, FAC 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. Full Name of Applicant 1. When applicable, please complete the appropriate section below. Attach extra sheets if necessary. Title/Position Name Stock % CORPORATION (CORP/INC) President Vice President Secretary Treasurer Director(s) Stockholder(s) LIMITED LIABILITY COMPANY (LLC/LC) Managing Member(s) and/or Managers Members (must be printed if there are no managing members or managers) LIMITED PARTNERSHIP (LTD/LP/LTDLLP) General Partner(s) Limited Partner(s) Bar Manager (Fraternal Organizations of National Scope only) DIRECT INTEREST Name of Individual or Entity (If a legal entity, list name under which the entity does business and its principles) Title/Position Name Stock % 2. Are there any persons not listed above who have guaranteed or co-signed a lease or loan, or any person or entity who has loaned money to the business that is not a traditional lending institution? Yes No If yes, and the terms create a direct interest in the business, you must list the person(s) or entity and indicate which of the below applies. Each directly interested person must submit fingerprints and a related party personal information sheet. Copies of agreements must be submitted with this application. Interest Rate Name Guarantor Co-signer Lender (List) Auth. 61A-5.0014, FAC 8 American LegalNet, Inc. www.FormsWorkFlow.com SECTION 7 – APPLICANT ENTITY FELONY CONVICTION Full Name of Applicant Has the applicant entity been convicted of a felony in this state, any other state, or by the United States in the last 15 years? Yes No If the answer is “Yes,” please list all details including the date of conviction, the crime for which the entity was convicted, and the city, county, state and court where the conviction took place. (Attach additional sheets if necessary) Auth. 61A-5.0014, FAC 9 American LegalNet, Inc. www.FormsWorkFlow.com SECTION 8 - AFFIDAVIT OF APPLICANT NOTARIZATION REQUIRED Full Name of Applicant “I, the undersigned individually, or if a registered legal entity for itself and its related parties, hereby swear or affirm that I am duly authorized to make the above and foregoing application and, as such, I hereby swear or affirm and agree that the place of business may be inspected and searched during business hours or at any time business is being conducted on the premises without a search warrant by officers of the Division of Alcoholic Beverages and Tobacco, the Sheriff, his Deputies, and Police Officers for the purposes of determining compliance with the beverage and retail tobacco laws.” “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 the foregoing information is true and that no other person or entity except as indicated herein has an interest in the alcoholic beverage license and/or tobacco permit, and all of the above listed persons or entities meet the qualifications necessary to hold an interest in the alcoholic beverage license and/or tobacco permit.” STATE OF________________ COUNTY OF______________ _________________________________________________ APPLICANT SIGNATURE _________________________________________________ APPLICANT SIGNATURE The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this ___________Day of_______________, 20_____, By _______________________________________who is ( ) personally (print name(s) of person(s) making statement) known to me OR ( ) who produced ___________________________________________as identification. ________________________________________________ Commission Expires: ___________________ Notary Public Auth. 61A-5.0014, FAC 10 American LegalNet, Inc. www.FormsWorkFlow.com SECTION 9 - CURRENT LICENSEE UPDATE DATA SHEET This section is to be completed for all current alcoholic beverage and/or tobacco license holders listed on the application to ensure the most up to date information is captured. Full Name of Applicant Last Name First M.I. Current Alcohol Beverage and/or Tobacco License Permit/Number(s) Date of Birth / / Street Address Social Security Number* - - City State Last Name First Zip Code M.I. Current Alcohol Beverage and/or Tobacco License Permit/Number(s) Date of Birth / / Street Address Social Security Number* - - City State Last Name First Zip Code M.I. Current Alcohol Beverage and/or Tobacco License Permit/Number(s) Date of Birth / / Street Address Social Security Number* - - City State Last Name First Zip Code M.I. Current Alcohol Beverage and/or Tobacco License Permit/Number(s) Date of Birth / / Street Address Social Security Number* - - City State Last Name First Zip Code M.I. Current Alcohol Beverage and/or Tobacco License Permit/Number(s) Date of Birth / / Street Address Social Security Number* - - City State Auth. 61A-5.0014, FAC 11 Zip Code American LegalNet, Inc. www.FormsWorkFlow.com