Form CRF-012 (9/11) 2012 Georgia Department of Revenue Alcohol & Tobacco Division PO Box 105458 Atlanta, Georgia 30348-5458 (404) 417-4900 ATD- alcohol.tobacco.lic@dor.ga.gov DATE: STATE TAXPAYER IDENTIFIER BUSINESS NAME ADDRESS ADDRESS CITY AREA CODE STATE TELEPHONE **BOND EXPIRES LIQUOR ALCOHOL LICENSE RENEWAL APPLICATION IMPORTANT: The Cut-Off date to secure your 2012 Alcohol License is January 3, 2012. RENEWAL FOR YEAR TOTAL FEE AFTER 12-31-2011 TOTAL FEE DBA (IF DIFFERENT) LOCATION ADDRESS (LINE 1) LOCATION ADDRESS (LINE 2) ZIP CODE CITY AREA CODE TELEPHONE STATE ZIP CODE COUNTY LICENSE NUMBER PRODUCTS SOLD BEER WINE FEI NUMBER "2012 Not Req'd" RELATIONSHIP SECTION TYPE NAME HOME/LOCATION SOCIAL SECURITY NUMBER ALCOHOL LICENSE SECTION OWNERSHIP TYPE LOCAL LICENSE ISSUED BY LICENSE TYPE TYPE OF BUSINESS AGRICULTURE LICENSE (IF APPLICABLE) CRF-012 (Rev. 9/11) Alcohol License Renewal (404) 417-4900 PLEASE MAIL THE ENTIRE FORM 2012 License Number Year State Taxpayer Identifier Total Amount Due MAIL TO: Georgia Department of Revenue Alcohol & Tobacco Division PO Box 105458 Atlanta, Georgia 30348-5458 Amount Paid See reverse side of voucher for renewal requirements to secure license before the cut-off date of January 3, 2012 BUSINESS NAME AND ADDRESS DO NOT STAPLE OR PAPER CLIP. REMOVE ALL CHECK STUBS. 054012000000000000000000004000000000007 American LegalNet, Inc. www.FormsWorkFlow.com Form CRF-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, attach additional sheets to respond completely.) 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 and no application changes (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 can be made only if our documentation has typographical errors. Changes to the mailing address are acceptable. Changes to the Trade Name can be made if a corrected Local License is submitted with the renewal application. **2012 Liquor Bond Requirement State Alcohol License renewals for 2012 will not require a Liquor Bond. The Department encourages retail dealers who purchased a multi-year bond, which includes 2012, to contact the bond insurer for a refund. You can renew on-line at https://gaefile.dor.ga.gov. The `s' means the site is secure. Your Social Security Number and credit card information will be encrypted and securely transmitted for verification and billing. Avoid the most common errors that cause rejection of your application and delay in receiving your license: 1) Application not signed by Alcohol Licensee. 2) Changes in the Alcohol Licensee, Physical Location, and/or Ownership Structure require submission of a New State Alcohol Application (CRF-009). 3) The correct fee is not remitted. The fees must be attached and must be in the form of cashier's check or money order. 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