Page 1 CRF-009 (Rev. 6/11) GEORGIA DEPARTMENT OF REVENUE ALCOHOL & TOBACCO DIVISION P.O. BOX 49728 Atlanta, GA 30359 Phone: 1 (877) 423-6711 Fax: (404) 417-4901 OR (404) 417-4318 STATE ALCOHOL LICENSE APPLICATION (RETAIL OR COMSUMPTION ON PREMISES FOR LIQUOR, BEER AND/OR WINE) (PLEASE PRINT OR TYPE) FOR OFFICE USE ONLY IDENTIFICATION SECTION 1 LICENSE YEAR FOR WHICH APPLICATION IS MADE: 2 IF YOU HAVE A STATE TAXPAYER IDENTIFIER (STI), E NTER HERE: 3 LEGAL BUSINESS NAME: 4 LOCATION ADDRESS: 5 CITY SUITE PHONE NUMBER STATE NAME OF LICENSEE: ZIP CODE SOCIAL SECURITY NUMBER: 6 IS LICENSEE A CORPORATION? If “Yes”, name and address of Registered Agent 7 Mailing Address (if different from the Location Address): 8 CITY: STATE: TYPE OF LICENSE (Check only one major category that applies) YES NO ALCOHOL INFORMATION SECTION RETAIL PACKAGE (Check all that apply) ZIP : CONSUMPTION ON PREMISE (Pouring) Check all that apply Beer – Fee $50.00 Beer – Fee $50.00 Wine – Fee $50.00 Wine – Fee $50.00 Liquor – Fee $100.00 + Investigation Fee $100.00 Liquor – Fee $100.00 + Investigation Fee $100.00 HOTEL IN-ROOM SERVICE (Check only one) Beer – Fee $50.00 Wine – Fee $50.00 Beer and Wine – Fee $100.00 Liquor – Fee $100.00 + Investigation Fee $100.00 Beer and Liquor – Fee $100.00 + Investigation Fee $100.00 Wine and Liquor – Fee $100.00 + Investigation Fee $100.00 Beer, Wine and Liquor – Fee $100.00 + Investigation Fee $100.00 9 TYPE OF BUSINESS (Check One) Hotel In-Room Service Club Tavern or Lounge Convenience Store Package Store Restaurant Grocery Service Station Other 10 LOCAL LICENSE ISSUED BY: (Check Only One) City of County of American LegalNet, Inc. www.FormsWorkFlow.com Page 2 CRF-009 (Rev. 6/11) (RETAIL OR COMSUMPTION ON PREMISES FOR LIQUOR, BEER AND/OR WINE) FOR OFFICE 11 USE ONLY TO YOUR KNOWLEDGE, HAS A STATE ALCOHOL LICENSE BEEN ISSUED AT THIS LOCATION WITHIN THE LAST THREE (3)YEARS? IF “YES”, COMPLETE AS MUCH OF THE FOLLOWING AS POSSIBLE FOR THE LAST LICENSE KNOWN YES NO NAME OF LICENSEE: LEGAL BUSINESS NAME: TRADE NAME/DBA NAME ALCOHOL LICENSE NO. & YEAR: 12 DATE DISCONTINUED: / / TOTAL FUNDS TO BE INVESTED BY ALL PARTIES: $ AMOUNT OF FUNDS INVESTED BY LICENSEE: PERSONAL $ BORROWED $ PERSONAL $ BORROWED $ AMOUNT OF FUNDS INVESTED BY OTHERS: 13 IS THIS APPLICATION FOR HOTEL IN-ROOM SERVICE? YES NO IF “YES”, LIST THE CORRESPONDING ALCOHOL LICENSE ISSUED TO OR APPLIED FOR AT THIS LOCATION. NAME OF LICENSEE: LEGAL BUSINESS NAME: TRADE NAME/DBA NAME: 14 ALCOHOL LICENSE NO: DO YOU COMPLY WITH THE DISTANCE REQUIREMENTS OF O.C.G.A. 3-3-21, O.C.G.A. 3-4-49 AND REGULATION 560-2-2-.12 BELOW? YES NO No person may knowingly and intentionally sell or offer to sell: A. Any retail package liquor within 600 feet of any school ground. B. Any retail package malt beverages or wine within 300 feet of any school ground. C. Any retail package liquor within 300 feet of any church building. D. Any liquor, malt beverages and/or wine within 300 feet of any government owned and operated alcohol treatment center. E. Any new retail package liquor within 500 yards of an existing licensed retail package liquor location. 15 DO YOU COMPLY WITH THE REQUIREMENTS OF REGULATION 560-2-2-.10 BELOW? YES NO Neither a retail dealer or retail consumption dealer, whether licensed in this State or not, nor any of his employees or members of such retail dealer’s or retail consumption dealer’s immediate family shall have, own or enjoy any ownership interest in, or partnership arrangement or other business association with the business of any wholesaler, manufacturer, producer, shipper, importer or broker. 16 IF “YES”, DO YOU COMPLY IS THIS APPLICATION FOR RETAIL PACKAGE LIQUOR? YES NO WITH THE REQUIREMENTS OF O.C.G.A. 3-4-21 AND REGULATION 560-2-2-.10, AS SHOWN BELOW, REGARDING THE LIMIT OF TWO (2) LICENSES PER PERSON? YES NO No person shall be issued more than two retail package liquor licenses, nor shall any person be permitted to have a beneficial interest in more than two retail package liquor licenses issued by the Department regardless of the degree of such interest. For the purposes of explanation and applicability of the Code: “Beneficial interest” as used here means: when a person holds the retail package liquor license in his own name, or when he has a legal, equitable or other ownership interest in, or has any legally enforceable interest or financial interest in, or derives any economic benefit from, or has control over a retail package liquor business. The term “person” shall include all members of a retail package liquor dealer licensee’s family; and the term “family” shall include any person related to the holder of the license within the first degree of consanguinity and affinity as computed according to the canon law which includes the following: spouse, parents, step-parents, parents-in-law, brothers and sisters, step-brothers and stepsisters, brothers-in-law and sisters-in-law, children, step-children and children-in-law. SIGNATURE SECTION I DECLARE UNDER PENALTY OF PERJURY, THAT THIS APPLICATION HAS BEEN EXAMINED BY ME, AND TO THE BEST OF MY KNOWLEDGE AND BELIEF IS TRUE, CORRECT, AND COMPLETE. Signature Title Date (THIS APPLICATION MUST BE SIGNED BY THE ALCOHOL LICENSEE. IF THE LICENSEE IS A CORPORATION, AN ACTIVE OFFICER OR MANAGING MEMBER MAY SIGN THE APPLICATION. A STAMPED SIGNATURE IS NOT ACCEPTABLE.) American LegalNet, Inc. www.FormsWorkFlow.com Page 3 CRF-009 (Rev. 6/11) Affidavit of Compliance with O.C.G.A. 50-36-1 “Verification of Lawful Presence within the United States” O.C.G.A. 50-36-1 requires that applicants applying for such things as licenses for public benefits complete a signed and sworn affidavit verifying the applicant’s lawful presence in the United States. Therefore, the applicant must answer the following questions: The applicant is a United States citizen or legal permanent resident at least eighteen (18) years old. Yes ______ No ______ The applicant is a qualified alien or nonimmigrant under the federal Immigration and Nationality Act, Title 8 U.S.C., as amended, at least eighteen (18) years old, and is lawfully present in the United States. The applicant’s alien number issued by the Department of Homeland Security or other federal immigration agency must be provided. Yes ______ No ______ Alien Number ____________________________________ O.C.G.A 50-36-1 states that “Any person who knowingly and willfully makes a false, fictitious, or fraudulent statement of representation in an affidavit executed pursuant to this Code section shall be guilty of a violation of Code Section 16-10-20.” I declare, under penalty of law, that this affidavit has been completed by me and is true and correct. ___________________________________________________________________________________________ Signature Title Date (Must be signed by applicant. If the applicant is a corporation, must be signed by an officer of the corporation. STAMPED SIGNATURE IS NOT ACCEPTABLE) I hereby certify that__________________________________________________________ is personally known, or verified by me, that the applicant signed this application after stating to me his or her personal knowledge and understanding of all statements and, under oath actually administered by me, has sworn that the statements and answers contained in this affidavit are true. This _________ day of _____________, ______ . _______________________________________ Notary Public AFFIX SEAL You must attach a copy of a secure and verifiable document as defined in O.C.G.A. 50-36-2. Such documents include a valid Georgia issued Driver's License or ID Card, a valid Driver's License issued by another State or an identification document issued by the United States Government. American LegalNet, Inc. www.FormsWorkFlow.com