Site I.D. # Page 1- Schedule-A 01/01/07 Schedule “A” Agent's, Solicitor's, Out-Of-State Brewer, Out-Of-State Microbrewer, and Beer Importer License Leave Blank – For ABC Use Only License # _____________________________ $ ________________________ Validating Number ________________________ Malt Beverage Administrator’s Approval _________________________________ Date ___________________________________ Distilled Spirits Administrator’s Approval __________________________________ Date ___________________________________ (A) Applicant’s name(s) or company to be licensed ____________________________________________________________________________ DBA (Name of Business) _____________________________________________________________________________________________ Address of premises to be licensed _____________________________________________________________________________________ City _______________________________________________ County __________________ State ________ 9 digit zip code ____________ Mailing address if different from above __________________________________________________________________________________ Telephone ( ) _______________________ Fax ( ) ______________________ Other Phone ( ) _______________________ Enter amount of fee enclosed $ _______________________________________________ List the type(s) of licenses(s) you are applying for __________________________________________________________________________ Enter the date you want this license to become effective ____________________________________________________________________ (B) 1. Does anyone named in this application have an interest in any kind of alcoholic beverage business (es) or the premises(s) of any alcoholic beverage business (es) other than that for which you are herein applying? If yes, describe the interest(s). __________________________________________________________________ ⃞ Yes ⃞ No 2. a. Has the applicant or any person named in this application been convicted of any felony in the past five (5) years? ⃞ Yes ⃞ No b. Has the applicant or any person named in this application been convicted of a misdemeanor directly or indirectly related to alcohol or a controlled substance in the past two (2) years? ⃞ Yes ⃞ No If yes, to either question you must attach a statement giving a full explanation, including dates of conviction(s). 3. Has a license been suspended, revoked or denied for the premises or any person named herein? If yes, attach a statement giving a full explanation, including dates of suspension, revocation, or denial. ⃞ Yes ⃞ No (C) 4. Are you applying for an ⃞ Agent's or Solicitor's Liquor & Wine License under KRS 243.340 or a ⃞ Non-Resident Agent's or Solicitor's Liquor and Wine License under 804 KAR 4:020? If yes, please complete the following. If no, skip to question #5. a. Give the following information for the past two years: Name of Employer _________________________________________ Address _____________________________________________ Date of Employment: From __________________________________ to __________________________________________________ Present Employer _________________________________________ Address _____________________________________________ Kentucky State ABC License Number ______________________________________________________________________________ b. Do you plan to work for a retail licensee while holding this solicitor’s license? c. Do you have any relatives holding a retail License? ⃞ Yes ⃞ No If yes, give relationship _________________________________________________________________________ Give the following information: Your home address __________________________________________________ Your Social Security # ______________________________, and your Date of Birth ________________________ Are you a Kentucky Resident? ⃞ Yes ⃞ No If yes, give date you established residency. ____________________ d. Are you a USA Citizen? e. ⃞ Yes ⃞ No ⃞ Yes ⃞ No Your employer must sign the following: I, _______________________________, a principal officer of ____________________________ Company, holder of Kentucky State ABC License Number __________________ does hereby offer employment as a solicitor or sales representative to the above applicant. Employer’s Signature _______________________________________________________ Date ______________________________ American LegalNet, Inc. www.FormsWorkflow.com Page 2- Schedule-A 01/01/07 Site I.D. # SCHEDULE “A” Page (2) (D) 5. Are you applying for an ⃞ Out-of-State Brewer License, (importing 25,000 or more barrels (775,000) of malt beverages annually?)) or a ⃞ Limited Out-of-State Brewer or Microbrewery License, (importing 25,000 barrels or less (775,000 gallons of malt beverages annually?)) Under 804 KAR 4:350. If your answer is No, skip to section F. a. Pursuant to KRS 243.180 and KRS 244.560, are you a licensed ⃞ beer wholesaler, or a ⃞ beer distributor? If yes, give the state where you are licensed ____________________ and your license number _______________________ ⃞ Yes ⃞ No b. Are you a licensed importer of a non-US brand of malt beverages? If yes, list the state where you are licensed ____________________ and your license number ________________________ ⃞ Yes ⃞ No c. List the brand(s) of malt beverages to be imported into Kentucky. ______________________________________________ d. Will the above-mentioned brand(s) be distributed from your warehouse? e. What is the address of your warehouse? __________________________________________________________________ f. ⃞ Yes ⃞ No Have you attached an actual label of your beer(s) that has been approved by the Federal Department of Treasury (TTB) Alcohol, Tobacco Tax and Trade Bureau, and a copy of their (COLA) Certificate of Label Approval for such label(s)? g. ⃞ Yes ⃞ No Have you attached a copy of your territorial agreement filed with the Kentucky Office of Alcoholic Beverage Control, which has been signed and dated? (ABC Form 714) h. ⃞ Yes ⃞ No Are you an importer of a foreign beer? If yes, have you attached authorization from the foreign brewery authorizing you to name a Kentucky Distributor to distribute the beer in a designated territory? ⃞ Yes ⃞ No ⃞ Yes ⃞ No (E) SOCIAL SECURITY NUMBER TITLE H W F O ⃞ Yes H W F O ⃞ Yes ⃞ No ⃞ No DATE OF BIRTH % OF OWNERSHIP ALL PHONE NUMBERS H = HOME W = WORK F = FAX 0 = OTHER LIST DATE & STATE WHERE YOU RESIDED IN PAST 5 YRS. NAME AND ADDRESS USA CITIZEN Complete the following for the business proprietor, partner(s) and all persons interested in the business to be licensed. List all owners, officers, directors, partners, managing members, members, and shareholders (unless publicly held). Show 100% of the ownership. If additional space is needed, please make an attachment. % % (F) AFFIDAVIT OF PERSON APPLYING FOR THE KENTUCKY ABC LICENSE (S) I, ___(print your name here)__________________________________________, do hereby swear or affirm that all statements contained in this application and all its attachments are true and correct to the best of my knowledge, information and belief. I further agree that I shall not engage in any activity involving alcoholic beverages at the premises described herein until I have been issued the appropriate license(s) by the Office of Alcoholic Beverage Control. Once the license(s) is issued, I hereby swear or affirm that I shall abide by all state and local statutes, regulations, and ordinances relating to the manufacture, sale, use, and trafficking in alcoholic beverages. Signature of Applicant ____________________________________________ Title ____________________________ Date _________________ Sworn or affirmed before me on this _____day of __________, year of ________. My commission expires ______________________________ Notary Public _______________________________________ County of _________________________________,State of __________________. (Canadian applicants are exempt from this notary requirement) American LegalNet, Inc. www.FormsWorkflow.com Page – 3 Schedule – A 01/01/07 SCHEDULE “A” TYPES OF LICENSES & FEES Check ⃞ the box(s) for the type(s) of license(s) you are applying for. To determine the ABC State License(s) fee, find the license type(s) in the left column, and then move right across the table to the fee boxes. Figure from the month your license will be issued. Licenses that are issued 6 months or more pay a full year fee and Licenses that are issued 6 months or less pay a half-year fee. Attach a certified check, cashier check, or a money order. WE MAY NOT ACCEPT CASH BY MAIL OR HAND DELIVERY Make check payable to: Kentucky State Treasurer PREFIX b FULL YEAR FEE HALF YEAR FEE AGENTS / SOLICITOR'S (liquor / wine) KRS 243.340 AS ⃞ 25.00 12.50 AGENTS / SOLICITOR'S (liquor / wine) 804 KAR 4:020 FOR NON-RESIDENTS OF KENTUCKY OAS ⃞ 100.00 50.00 OUT-OF-STATE BREWER 804 KAR4:350 (Importing 25,000 or more barrels of malt beverages annually.) OSB ⃞ 1500.00 750.00 LIMITED OUT-OF-STATE BREWER 804 KAR 4:350 (Importing 25,000 or less barrels of malt beverages annually.) LSB ⃞ 250.00 125.00 LICENSE TYPE TOTALS American LegalNet, Inc. www.FormsWorkflow.com Page 4-Schedule-A 01/01/07 SCHEDULE “A” PAGE (4) CHECK LIST 1. Have you answered each question fully and checked the type of licenses you are applying for? ⃞ Yes ⃞ No 2. Have you attached a certified check, cashier’s check or money order, payable to: Kentucky State Treasurer for the license fee? NO CASH!!!! ⃞ Yes ⃞ No 3. Have you signed and had your application notarized? ⃞ Yes ⃞ No 4. If you are applying for an agent’s or solicitor's license, has your employer signed this application? ⃞ Yes ⃞ No 5. If you are applying as an Out-of-State Brewer, Out-of-State Importer, or an Out-of-State Distributor, have you attached the following? • • • Actual label of your beer that has been approved by the Federal Department of Treasury, T.T.B.? ⃞ Yes ⃞ No Agreement between you and a Kentucky malt beverage distributor Completed on ABC Form 714 titled “Malt Beverage Brand Approval and Distributor Territorial Designation Agreement in Kentucky”? ⃞ Yes ⃞ No If you are applying as an importer of a foreign beer, have you attached A letter from the foreign brewery authorizing you to name a Kentucky Distributor to distribute the beer in a designated territory or obtain their signature of approval on ABC Form 714? ⃞ Yes ⃞ No You may now forward this application, all attachments, and your state license fee to: Commonwealth of Kentucky Office of Alcoholic Beverage Control 1003 Twilight Trail Frankfort, Kentucky 40601-8400 Telephone (502) 564-4850 Fax (502) 564-1442 Visit our web site http://abc.ky.gov American LegalNet, Inc. www.FormsWorkflow.com