ALCOHOL LICENSE NON-RETAIL RENEWAL APPLICATION Form ATT-012 (9/11) 2012 Georgia Department of Revenue Alcohol & Tobacco Division PO Box 740395 Atlanta, Georgia 30374-0395 (404) 417-4870 ATD- alcohol.tobacco.lic@dor.ga.gov IMPORTANT: The Cut-Off date to secure your 2012 Alcohol License is January 3, 2012. DATE: STATE TAXPAYER IDENTIFIER RENEWAL FOR YEAR AFTER 12-31-2011 LICENSE NUMBER TOTAL FEE DBA (IF DIFFERENT) BUSINESS NAME LOCATION ADDRESS (LINE 1) ADDRESS LOCATION ADDRESS (LINE 2) ADDRESS CITY STATE AREA CODE ZIP CODE TELEPHONE WINE CITY STATE AREA CODE PRODUCTS SOLD BEER TOTAL FEE **BOND EXPIRES TELEPHONE ZIP CODE COUNTY FEI NUMBER LIQUOR RELATIONSHIP SECTION TYPE NAME HOME/LOCATION SOCIAL SECURITY NUMBER ALCOHOL LICENSE SECTION OWNERSHIP TYPE LICENSE TYPE LOCAL LICENSE ISSUED BY ATT-012 (Rev. 9/11) Alcohol License Renewal (404) 417-4870 TYPE OF BUSINESS AGRICULTURE LICENSE (IF APPLICABLE) PLEASE MAIL THE ENTIRE FORM 2012 MAIL TO: Georgia Department of Revenue Alcohol & Tobacco Division PO Box 740395 Atlanta, Georgia 30374-0395 See reverse side of voucher for renewal requirements to secure license before the cut-off date of January 3, 2012 License Number Year State Taxpayer Identifier Total Amount Due Amount Paid BUSINESS NAME AND ADDRESS DO NOT STAPLE OR PAPER CLIP. REMOVE ALL CHECK STUBS. American LegalNet, Inc. www.FormsWorkFlow.com Form ATT-012 (9/11) During the previous twelve months have you, the Licensee, or any other person having any interest in the business for which this application has been made, ever been detained, arrested, indicted or convicted for any offense by any state, county, city, federal or foreign officer, or any other government authority? Yes No If “Yes”, give full details. Failure to make a full disclosure in response to this question will result in a denial of the application or a revocation of the license issued. (If neccessary, attach additional sheets to respond completely.) Does the Licensee, Corporation, Owner, or any other Partner have any interest in, or control over any other beverage alcohol business in the State of Georgia? Yes No SIGNATURE SECTION Before signing this application, check all answers and explanations to see that all questions are answered fully and correctly. This application is to be executed under oath and subject to the penalties of false swearing and it includes all attached sheets submitted herewith. Applicant understands that any license issued pursuant to this application is conditioned upon the truth of the answers and statements made herein and that any false answers and statements herein shall constitute cause for the suspension or revocation of any license is issued pursuant to this application which would require a different answer to any question contained in this application, or any personal statement which is made a part of this application, such change must be reported as an amendment to this application as specified by Revenue Department regulations. The failure to make such an amendment shall be cause for the revocation of any license issued pursuant to this application. Indicate here that this is fully understood. If there has been a change in the above information during the past year (except for the acceptable changes listed below), do not change this form. This includes ownership, financial, contractual, business, or any other beneficial interest. In such case you must obtain from the Department and return an appropriate application form. Your signature on the enclosed renewal application form certifies that you have previously furnished all required information and that such information is still true and correct. I declare under penalty of false swearing that this application has been examined by me, and to the best of my knowledge and belief is true, correct and complete. The cut-off date for the 2012 license renewal is January 3, 2012. ____________________________________________ Signature ______________________________________ Title ___________________ Date (Must be signed by licensee or corporate officer if the licensee is the corporation) Any alcohol renewal request postmarked by November 1, 2011, having no outstanding tax liabilities, no application changes (see*), and all paperwork in order (see**), will receive a 2012 license no later than January 3, 2012. To avoid penalties all alcohol licenses must be submitted by December 31, 2011. *Acceptable Changes to the renewal document. Changes to business location of an in-state business can be made only if our documentation has typographical errors. Changes to the mailing address are acceptable. A NEW APPLICATION will be necessary for changes to: Business Location (in-state only), Business Structure or Alcohol Licensee. Adding additional officers incurs an investigation fee (in-state only). A NEW APPLICATION submitted at renewal time will require a minimum of 8-10 weeks for processing. **Paperwork in Order All renewal documents must be signed by the Alcohol Licensee (or corporate officer if corporation is licensee) exactly as shown on the renewal document (do not use initials if the renewal shows a full name). All renewals require a properly completed original bond with original signatures. The surety company must sign and date the bond and ensure the company seal is present. Also, the power of Attorney must be attached, notarized and sealed. A Rider is attached if there is any incorrect information on the bond. Whiteout is not acceptable on the bond. ***Ask your Surety Company about a five (5) year bond. ***Current year bond required for all wholesalers. Avoid the most common errors that cause rejection of your application and delay in receiving your license: 1) Application is signed by the wrong person. Application must be signed by the Alcohol Licensee (or corporate officer if corporation is licensee). 2) The correct fee is not remitted. 3) A seperate payment must be submitted for each location. Cash payments will not be accepted. 4) If you do not mail the entire form back to the Department of Revenue (Please do not detach any parts of this form). American LegalNet, Inc. www.FormsWorkFlow.com