081910 State of Louisiana Office of Alcohol and Tobacco Control 8585 Archives Ave., Suite 220 P.O. Box 66404 Baton Rouge, LA 70896-6404 Telephone (225) 925-4041 · Fax (225) 925-3975 Bobby Jindal Governor Schedule A A Schedule “A” must be executed by the manager, owner, each partner, each officer, director, and every stockholder owning more than 5 percent of the capital stock. 2. Trade Name of Business: 1. Owner name of business (individual, partnership, corporation, LLC): 3. Name of person to be certified (Enter Full Legal Name): 4. Daytime Telephone #: ( ) 5. Race: 6. Sex: - 7. Residence Address (street/city/state/zip): 8. Date of Birth: 12. Social Security Number: 9. Present Age: 10. Place of Birth: 11. Naturalization Number (if applicable): 13. Your Driver’s License Number & State: 15. Are you a citizen of Louisiana? 14. Are you a citizen of the United States? Yes No 16. Name, Social Security Number, and Date of Birth of spouse: Yes No 17. Have you continuously resided in Louisiana for the past two years? Yes No 18. Do you or your spouse own or hold interest in any other business holding a state retail beer and/or liquor permit? Yes No If yes, enter permit number: 18a. Trade Name of Business: 18b. Location Address (street/city/state/zip): Note: If this person is an Officer, Member, or Partner in another entity that maintains a state alcohol permit, answer “yes” and list the business above. If there is more than one business, attach a list disclosing each. 19. Do you or your spouse own or hold interest in any business holding a wholesale permit or solicitors permit? Yes No If yes, enter the name of business: 20. Have you or your spouse ever been convicted of a felony? This includes any offense adjudicated under Article 893. Yes No If yes, complete Schedule “F” as provided by this office. 21. Have you or your spouse ever been convicted of violating any liquor or beer regulatory statute or rule? Yes No 22. Have you or your spouse ever been convicted of solicitation for prostitution, pandering, letting premises for prostitution, contributing to the delinquency of a juvenile, keeping a disorderly place, or dealing in narcotics? Yes No 23. Have you of your spouse had a license or permit to sell or deal in alcoholic beverages revoked within the last two years No prior to the filing of this schedule? Yes 24. Have you or your spouse ever been denied an alcoholic beverage permit? Yes No 25. If the response to Questions 20 and 22 is “yes,” state the offense, date, location, and provide certified copied of the disposition to include documents relative to felony pardons. If the response to Questions 21, 23, and 24 is “yes,” state the offense, date, and location. Apply attachment(s) to this document if necessary. 26. Have you or your spouse ever had or used any name(s) other than the one stated above? (Official name change, maiden name, alias, nickname, etc.) Yes No If yes, please list. 27. Are you employed by the State of Louisiana? Yes No If yes, enter the name of the department. 28. Is this application being made by you to permit any person other than yourself to secure a beer/liquor permit in your name for his/her benefit? Yes No Affidavit I swear that I have read each of the above questions and the answers that I have given are true and correct to the best of my knowledge; and that I meet the qualifications and conditions set out in R.S. 26:80 and 26:280. Signature: Title: Print/Type your name: Sworn to and subscribed to me this in the parish/county of Notary Public’s Signature: day of , 20 State of Print Name of Notary Public: American LegalNet, Inc. www.FormsWorkFlow.com