Idaho State Police Alcohol Beverage Control 700 S. Stratford Dr. Ste 115 Meridian, ID 83642 Phone: (208) 884-7060 AFFIDAVIT ­ RELEASE OF LICENSE I/we, the undersigned, regarding herein named license: Alcohol License No.: _____________________________; Premises ID No.: _________________________________, doing business as _____________________________________, located in the city of ________________________, County of _______________________, State of Idaho, transferred on this _______ day of ___________________, 20____, the use of said license to the following person(s) or entity (new applicant name(s)): ____________________________________________ _______________________________________ Name Address ____________________________________________ _______________________________________ Name Address ____________________________________________ _______________________________________ Name Address DISCLAIMER: This affidavit cannot be construed to affect any agreements between assignor(s) and assignee(s). Assignor's Signature(s): _______________________________________ _______________________________________ _______________________________________ On this ________day of _________________________20 _____, before me, the undersigned, a notary public in and for the State of _______________, personally appeared ____________________________________________ known to me to be the person(s) whose name(s) is/are subscribed to the foregoing instrument and acknowledged to me that (s)he/they executed the same. __________________________________________ Notary Public Residing at ________________________________ My Commission Expires ____________________ (Seal) EH 10.02-07 Affidavit of Release of License 9/2009 American LegalNet, Inc. www.FormsWorkFlow.com