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Beer And Wine Application Form. This is a Idaho form and can be use in State Police Statewide.
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Tags: Beer And Wine Application, Idaho Statewide, State Police
Idaho State Police
Beer & Wine Application
1. □ New
□ Change
Premise File Number _________
□ Transfer (Fee is $20 for each type of license transferred)
2. License Type and Fees
Proposed Opening Date _____________________
□
□
□
□
□
□
Keg Beer (Kegs to Go) $20.00
Wine by the Drink
$100.00
On Premise Consumption
Beer $50.00
Wine by the Bottle $100.00
Restaurant (Must Qualify)
Total Fee enclosed: ________
3. Applicant Information
License to be issued to:_________________________________________________________
(Applicant Name: Individual(s), Partnership, Corporation or LLC)
Doing Business As:____________________________________________________________
Located At:___________________________________________________________________
City:_______________________________ County______________ Zip__________________
Former Business Name_________________________________________________________
Mailing Address:_______________________________________________________________
(Include City, State and Zip Code)
Daytime Telephone:___________________ Nighttime Telephone:_______________________
Federal or State Tax I.D. Number ____________________________________
4. List all individuals, partners, corporate officers, directors, stockholders (10 primary), instate manager and LLC/LLP members/partners.
(Name)___________________________(Home Address)____________________________________
(Title)____________(SSN)_____________(DOB)_____________(Contact Phone Number)___________________
(Name)___________________________(Home Address)____________________________________
(Title)____________(SSN)_____________(DOB)_____________(Contact Phone Number)___________________
(Name)___________________________(Home Address)____________________________________
(Title)____________(SSN)_____________(DOB)_____________(Contact Phone Number)___________________
(Name)___________________________(Home Address)____________________________________
(Title)____________(SSN)_____________(DOB)_____________(Contact Phone Number)___________________
(Name)___________________________(Home Address)____________________________________
(Title)____________(SSN)_____________(DOB)_____________(Contact Phone Number)___________________
5. Does anyone listed above have any direct or indirect interest in any other business licensed
for the sale of beer, wine or liquor by the drink? □ NO □ YES (Explain-Include Premise #)
_____________________________________________________________________
6. Has anyone listed above ever had an alcohol license denied, suspended or revoked?
□ NO □ YES
(Attach Explanation)
7. Has anyone listed above ever been charged with a felony or an alcohol related
misdemeanor? □ NO
(Over)
□ YES
(Attach Explanation)
Alcohol Beverage Control, P O Box 700, Meridian, ID 83680-0700
(208) 884-7060, Toll Free (888) 222-1360
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8. Applicant Financial Information
List all Assets of the Applicant:
____________________________________________________________________________
____________________________________________________________________________
List all Liabilities of the Applicant:
____________________________________________________________________________
____________________________________________________________________________
Does anyone not previously listed have any financial interest (direct or in-direct) in the business?
□ No □ Yes (If yes, explain)
(Name)
(Address)
(Explanation)
____________________________________________________________________________
____________________________________________________________________________
Business Bank Name and Address:
____________________________________________________________________________
Persons Authorized to sign on bank account:
____________________________________________________________________________
9. List the owner of your building: ________________________________________________________
(Include a copy of your warranty deed or building lease)
10. Premise Diagram/Floor Plan (No architectural blue prints)
Attach a sketch showing the entire area proposed to be licensed, all entrances, exits, locations of bars, back bars,
bar stools, booths, tables, coolers (for off premise), coin operated amusement devises and the place where the
licenses are regularly displayed. Indicate in the margin the direction and distance to the nearest school, church or
other places of worship measuring from the nearest entrance of the licensed premises to the school, church or
other place of worship if within 300 feet. Also include a copy of your permits for health, safety and zoning
from the governmental agency with zoning jurisdiction over the facility’s location.
11. Read:
The applicant hereby affirms that he/she is the bona fide owner of the business, is eligible and has none of the disqualifications
for a license as provided by Title 23, Chapter 9, 10,11, 13, 14, Idaho code or any amendments thereto. I/we hereby certify that
there have been no changes in the above named business, ownership, directors, stockholders, partners or members during the
past licensed year, except as indicated herein.
An application for and acceptance of a license by a retailer shall constitute consent to, and be authority for, entry by the director
or his authorized agents, upon any premises related to the licensee’s business, or wherein are or should be, kept, any of the
licensee’s books, records, supplies or other property related to said business, and to make the inventory, check and
investigations aforesaid with relation to said licensee or any other licensee, as per Idaho code sections 23-1006 & 23-1314.
12. Sign
I/we have also read all of the above and declare under penalty of perjury that each and every statement is true and correct.
____________________________________ ____________________ _______________
Applicant Signature
Title
Date
Subscribed and sworn to before me this ______ day of ______________, 20____.
__________________________________________
Notary Public
(Seal)
Residing At__________________________________
My Commission Expires:________________________
ABC-App Beer/Wine
Revised 10/2002
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