Page 1 – Advertisement-Basic-Revised 02/24/05 EXAMPLE OF PUBLIC NOTICE WHEN APPLYING FOR AN ABC LICENSE KRS 243.360 requires a person to first advertise their intention to apply for these licenses in the newspaper. Please use the following to assist you with this requirement. Place your advertisement in the legal section of the newspaper having the largest circulation for the county or city where your premises will be located. YOUR ADVERTISEMENT SHOULD READ AS FOLLOWS: (Fill in the blanks) _________________________________________________________________________________, Mailing address (List the Name of each individual owner(s) or the name of the Corporation, Ltd, or L.L.C. the license will be issued under) ________________________________________________________________________ Hereby declares intention(s) (Include Street, City, State and Zip) to apply for a _____________________________________________________________________________license(s) (List all license types you are applying for. (Example) Retail Beer, Retail Liquor by the Drink, Retail Liquor by the Package, Restaurant Liquor by the Drink, Restaurant Wine by the Drink, Alcoholic Beverage Caterer's, Retailer's Liquor Drink Sampling, Retailer's Liquor Package Sampling, Alcoholic Beverage Limited Restaurant by the Drink, Alcoholic Beverage Golf by the Drink, and so on…) (Be sure to refer to your ABC Schedule form for a complete list of all the license types you are making application for.) no later than ______________________________________________________, The business to be licensed will be (Enter the date you intend to make application to the State ABC) located at _______________________________________________________________ Kentucky _______________. (List the EXACT street address and city where the ABC license is to be issued) (Zip) doing business as ________________________________________________________________________________ (List the name of your business (D.B.A.)) The (owner(s); Principal Officers and Directors; Limited Partners; or Members) are as follows: _____________________, Title or position _____________________, Title or position _____________________, Title or position _____________________, Title or position _____________________, Title or position _____________________, ________________________ of ____________________________________________ Name Home address, city, state and zip code ________________________ of ____________________________________________ Name Home address, city, state and zip code ________________________ of ____________________________________________ Name Home address, city, state and zip code ________________________ of ____________________________________________ Name Home address, city, state and zip code ________________________ of ____________________________________________ Name Home address, city, state and zip code ________________________ of ____________________________________________ Any person, association, corporation, or body politic may protest the granting of the license(s) by writing the Department of Alcoholic Beverage Control, 1003 Twilight Trail, Frankfort, Ky. 40601-8400, within 30 days of the date of this legal publication. (End of advertisement) Forward a clipping of this advertisement along with the Affidavit of Publication to: Kentucky Office of Alcoholic Beverage Control 1003 Twilight Trail Frankfort, Kentucky 40601-8400 (502) 564-4850 phone (502) 564-1442) fax American LegalNet, Inc. www.FormsWorkflow.com Page 2 – Advertisement Rev. 02/24/2005 Commonwealth of Kentucky Office of Alcoholic Beverage Control 1003 Twilight Trail Frankfort, Kentucky 40601-8400 (502) 564-4850 phone (502) 564-1442 fax GLUE OR TAPE CLIPPING HERE AFFIDAVIT OF PUBLICATION Attesting Publication of Intention to Engage in an Alcoholic Beverage Business The following Affidavit of Publication is to be executed by an officer of the newspaper in which the application advertised, one time before the date of application for an alcoholic beverage license, his/her intention to engage in the business authorized by the license(s) applied for. A clipping of the advertisement must be attached to this Affidavit of Publication. _____________________________________________________________of ________________________________ (Name of Officer at Newspaper) (City) (State) Being first duly sworn, says that he / she is __________________________________________________________ (Title of Position at Paper) of the _____________________________________________________ a newspaper printed and published in the (Name of Newspaper) State of ___________County of _________________________, and having a general circulation in the County of ______________________________, Kentucky, and that the attached advertisement is a true copy and has been Published in said newspaper on the following date(s): ________________________________________________ Signature of Officer _____________________________________________ Subscribed and sworn to before me, a Notary Public within and for the State and County aforesaid, by ____________________________ to me personally known, this __________day of _________ (year) _________ My Commission expires the _________day of ________________________________________ (year) _________ County of ________________________ Notary Public ___________________________________________ THIS AFFIDAVIT PROPERLY EXECUTED MUST BE ATTACHED TO THE ABC APPLICATION FOR LICENSING. American LegalNet, Inc. www.FormsWorkflow.com LEASE AGREEMENT I, (We) ____________________________________________________, hereby agree to lease to ___________________________________________, the premises located at ____________________________________________, ____________________________________________, in _________________________County, Kentucky. The said lease shall be for a term of _____________________________, beginning _____________________and ending _________________________. The rent shall be payable at a rate of ____________________________. I understand and agree upon, that the premises herein named shall be used for lawful purposes only. Lessor X_____________________________ Lessor X_____________________________ Lessee X_____________________________ Lessee X_____________________________ Subscribed and sworn to before me, a Notary Public, on this the _______ day of ___________________________, 20_______, by the above Lessor and Lessee. Notary Public __________________________ My commission expires _____________________________________________. American LegalNet, Inc. www.FormsWorkflow.com ABC Edu. Fin. Asst. Self-Certification 12/20/05 SELF-CERTIFICATION FOR COMPLIANCE WITH KRS 164.772 Default in repayment obligation under financial assistance program – Professional licensing and certification – Notification. This form must be completed (signed and dated) by all persons interested in this application, including, but not limited to, officers, partners, and managing members. If this involves more than one person, make copies in order that each such interested person completes this form. Certification of Repayment of Educational Financial Assistance I, _______________________________________________, am an applicant for a license related to alcohol or alcoholic beverages issued by the Kentucky Office of Alcoholic Beverage Control. I hereby certify that I am not in default of a repayment obligation, such as a student loan repayment, under any financial program administered by the Kentucky Higher Education Assistance Authority (KHEAA). ________________________________________ Signature of applicant _____________________ Date RETURN THIS COMPLETED FORM TO STATE ABC ALONG WITH YOUR APPLICATION American LegalNet, Inc. www.FormsWorkflow.com COMMONWEALTH OF KENTUCKY Page 1 ABC Basic application 01/01/07 Site I.D. # OFFICE OF ALCOHOLIC BEVERAGE CONTROL 1003 Twilight Trail Frankfort, Kentucky 40601-8400 502.564.4850 phone 502.564.1442 fax “BASIC APPLICATION FOR ALCOHOLIC BEVERAGE LICENSES” Applications may be returned if all questions are not answered completely. Leave Blank – For ABC Use Only License # __________________ $______________ Val._______________ License #__________________ $______________ Val. ____________ License # __________________ $______________ Val._______________ License# __________________ $______________ Val. ____________ Malt Beverage Administrator’s Approval _________________________________________________________________ Date _____________________ Distilled Spirits Administrator’s Approval _________________________________________________________________ Date ____________________ (A) 1. Applicant’s name(s) or company to be licensed _________________________________________ DBA (Name of Business) _______________________________________________________________ (B). 2. Tax numbers (must be issued in the applicant’s name). Address of premises to be licensed _______________________________________________________ Ky. Sales & Use Tax # _____________ City ______________________ County _____________ State ________ 9 digit zip code ____________ Ky. Withholding Tax # ______________ Mailing address if different from above ____________________________________________________ Contact person 8:00 am – 4:30 pm _____________________e-mail address _____________________ Ky. Corporate Tax # _______________ Contact phone___________________Fax__________________Premises phone __________________ Federal EIN #_____________________ List all ABC Schedule(s) you have attached ___________________ Fee enclosed $________________ (C) 3. 4. 5. List all types of licenses you are applying for _______________________________________________________________________________ What Month do you want your license(s) to become effective? _________________________________________________________________ Describe the type of business you will operate and list how you will sell alcoholic beverages. _________________________________________ Check all that apply: Beer: By the drink only, By the package only, Both by the drink and package. Wine Distilled Spirits: By the drink only, By the package only, Both by the drink and package. 6. Are you the owner of the real estate where these premises are to be licensed?......................................................................................⃞Yes ⃞No If no, you must attach a signed copy of your lease. ABC will not issue or renew any license(s) unless this lease extends through the full period of your license expiration date. List the name of the owner of the premises real estate____________________________________________ Give date lease expires____________ H W F SOCIAL SECURITY NUMBER TITLE 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 (D) 7. 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. ⃞ Yes ⃞ No % O H W F ⃞ Yes ⃞ No % O H W F ⃞ Yes ⃞ No % O Please state in section D7 if this is a publicly held company. American LegalNet, Inc. www.FormsWorkflow.com Page 2 ABC Basic application 01/01/07 Site I.D. # (E) 8. Is the applicant a corporation, limited partnership, or limited liability company, in good standing with the Ky. Secretary of State?......⃞Yes ⃞No List the State Incorporated or organized in _______________________________________________________________________ Attach a copy of your Articles of Incorporation or Articles of Organization. If incorporated or organized in another state, attach a Certificate of Authority to do business in Kentucky. 9. Is the entire license fee paid by the applicant and by no other person?....................................................................................................⃞Yes ⃞No 10. Are the premises to be licensed located within an incorporated city or town?...........................................................................................⃞Yes ⃞No If yes, list the name of the city or town __________________________________________________________________________ 11. Have you ever been licensed to sell alcoholic beverages?........................................................................................................................⃞Yes ⃞No If yes, give the name of the state and license number(s) ____________________________________________________________ If in Kentucky, are you transferring this license to a new location?............................................................................................................⃞Yes ⃞No 12. Does anyone named in section D 7 of this application have any interest in any kind of alcoholic beverage business or the premises of any alcoholic beverage business other than that for which you are herein applying?............................................................................⃞Yes ⃞No If yes, describe the interest(s) _________________________________________________________________________________ 13. Has the applicant or any person named in section D 7 been convicted of any felony in the past five (5) years or been convicted of a misdemeanor directly or indirectly related to alcohol or a controlled substance within the past two (2) years?.........................................⃞Yes ⃞No If yes, you must attach a statement giving a full explanation, including date(s) of conviction(s). 14. Has a license been suspended or revoked or denied for the premises to be licensed or any person named in section D7 of this Application herein? If yes, attach a statement giving a full explanation, including dates of suspension, revocation, or denial...................⃞Yes ⃞No 15. Are the premises to be licensed and the entrance located on the street level?..........................................................................................⃞Yes ⃞No If no, is the business a hotel, club or restaurant?........................................................................................................................................⃞Yes ⃞No 16. a. Have the premises applied for been licensed to sell alcoholic beverages in the past twelve months?...............................................⃞Yes ⃞No b. c. d. Are the premises currently licensed?...................................................................................................................................................⃞Yes ⃞No If yes, give the Kentucky License number (s) __________________________________________________________________ Is the license being transferred to you?...............................................................................................................................................⃞Yes ⃞No e. Are you acquiring an interest in the existing business?.......................................................................................................................⃞Yes ⃞No If yes, check all the following boxes that apply to you. ⃞ Inventory ⃞ Ownership by purchase of assets ⃞ Leases ⃞ Fixtures and Equipment ⃞ Ownership by purchase of shares ⃞ Other _______________________________________________ (F) 17. THE SELLER SHOULD COMPLETE THIS SECTION IF ITEM # 16 HAS BEEN ANSWERED “YES” OR IF SOMEONE IS TRANSFERRING THEIR LICENSE (S) TO YOU. I (we), _____________________________________________________________________________the seller(s) or owner(s) of the business known (Enter the exact name(s) that appears on the current license(s) as_______________________________________ located at ______________________________________________ Kentucky, am the holder of a ⃞ Malt Beverage (beer) ⃞ Liquor by Drink ⃞ Liquor by Package ⃞ ____________ (other) license(s). The license number(s) is (are) ___________________________. I hereby represent that I have agreed to convey all license privileges (permitted by law) to _____________________________________________________________. I (we) understand that I (we) may not relinquish control of the business, (Enter the exact name(s) that is applying to become the new licensee) premises, or my interest in the licenses until such time as the buyer’s application has been approved by the Office of Alcoholic Beverage Control. Signature of Seller __________________________________________________________________ Title _________________ Date __________ (If a partnership, all partners must sign. If a corporation, only one officer must sign) 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) (G) 18. AFFIDAVIT OF BUYER OR NEW PERSON APPLYING FOR THE 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 Buyer or New 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 Schedule – I 01/01/07 Site ID # SCHEDULE “I” INDUSTRIAL ALCOHOL AND NONBEVERAGE ALCOHOL VENDOR LICENSE LEAVE BLANK – FOR ABC USE ONLY License # ________________ $ ____________ Validating # _____________ License # _____________ $ ___________ Validating # __________ Distilled Spirits Administrator’s Approval__________________________________________________________________ Date _______________ Malt Beverage Administrator’s Approval __________________________________________________________________ Date _______________ (A). Applicant’s name(s) or company to be licensed _____________________________________________________ D.B.A. (Name of Business) _______________________________________________________________________ Address of premises to be licensed _______________________________________________________________ (B). 1. Are you applying for a Special Industrial Alcohol License? ……………………..…………………………….…⃞ Yes ⃞ No If yes, KRS 243.320 requires you to purchase your alcohol only from a distiller or nonbeverage alcohol vendor licensee and to be used for non-beverage purposes only. a. Checkb the following boxes that apply to you. Alcohol used for the following purposes: ⃞ denatured alcohol products ⃞ pharmaceutical ⃞ antiseptic ⃞ toilet preparations ⃞ flavoring extracts ⃞ syrups and food products ⃞ scientific ⃞ chemical ⃞ mechanical ⃞ industrial products. 2. Are you applying for a Special Nonindustrial Alcohol License? ……………………………………………..….⃞ Yes ⃞ No If yes, KRS 243.330 allows you to import alcohol or purchase alcohol in Kentucky only from a holder of a Special Nonbeverage Alcohol Vendor Licensee and to use it only for nonbeverage purposes. a. Check b the following boxes that apply to you. ⃞ Bona fied hospital ⃞ laboratory ⃞ museum ⃞ Educational or charitable institution ⃞ drug store employing a licensed pharmacist ⃞ licensed physician 3. Are you applying for a Special Nonbeverage Alcohol Vendor’s License? ……………………………….…..⃞ Yes ⃞ No If yes, KRS 243.310 allows you to sell to Special Industrial Alcohol and Special Nonindustrial Alcohol Licensees. (C). I do hereby solemnly swear or affirm that all statements contained in this application and all attachments are true and correct to the best of my knowledge, information and belief. I incorporate this schedule into my basic application for a Kentucky alcoholic beverage license. I understand I may not begin to operate with alcohol activity until the Kentucky ABC Office has issued my license(s). I further swear or affirm I shall abide by all state and local statutes, regulations, and ordinances relating to the manufacture, sale, and use of and trafficking in alcoholic beverages. Signature of Applicant _________________________________________Title _______________Date __________ You may now forward this application, the ABC Basic 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) 654-1442 http://abc,ky.gov/ American LegalNet, Inc. www.FormsWorkflow.com Page 2 Schedule – I 01/01/07 Site ID # TYPES OF LICENSES & FEES To determine the ABC license fee, find the license type(s) in the left column, and then move right across the table. Licenses issued 6 months or more pay a full year fee. Licenses issued less than 6 months pay one-half year fee. Attach a certified check, cashier check, or a money order for your license fees. Make payable to: KENTUCKY STATE TREASURER WE MAY NOT ACCEPT CASH! LICENSE TYPE PREFIX b FULL YEAR FEE HALF YEAR FEE Pay this amount Pay this amount SPECIAL INDUSTRIAL ALCOHOL, KRS 243.320 IA ⃞ 50.00 25.00 SPECIAL NONINDUSTRAIL ALCOHOL, KRS 243.330 NI ⃞ 50.00 25.00 NBA ⃞ 50.00 25.00 SPECIAL NONBEVERAGE ALCOHOL VENDOR, KRS 243.310. CHECK LIST 1. Have you answered each question fully? ⃞ Yes ⃞ No 2. Have you signed and had your application notarized? ⃞ Yes ⃞ No 3. Have you attached a certified check, cashier check or money order, payable to: Kentucky State Treasurer for your license fees and a separate check for your Ky. background checks? We may not accept cash. ⃞ Yes No 4. Have you attached a signed and dated copy of your lease? ⃞ Yes No You may now forward this application, the ABC Basic 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 http://abc.ky.gov American LegalNet, Inc. www.FormsWorkflow.com