12072006 LOUISIANA DEPARTMENT OF REVENUE OFFICE OF ALCOHOL AND TOBACCO CONTROL SOLICITOR SCHEDULE “A” When a manager or agent is employed, this schedule must be executed by that person, and by each member of a partnership or stockholder of a corporation owning more than five per centum (5%) of capital stock of corporation, which makes application for permit as provided by Chapter 1 and 2, Title 26, of the Louisiana Revised Statutes of 1950 as amended. To: Louisiana Department of Revenue Office of Alcohol and Tobacco Control PO Box 66404 Baton Rouge, LA 70896 Your Name This Schedule “A” must be submitted by each applicant. Name of Wholesaler Address of Wholesaler Residence Address Drivers License Number Social Security Number Date of Birth Place of Birth Are you a citizen of the Are you a citizen Are you over 18 years How did you become a citizen? U.S.? of Louisiana? of age? YES NO YES NO YES NO Have you ever been convicted of a felony under the laws of the United States, Louisiana, or Have you resided in Louisiana continuously of any other state? If yes, a proof of pardon and restoration of citizenship must be submitted for a period not less than 2 years, next with this application? preceding date of filing this application? YES NO YES NO Have you ever been convicted in the United States, Louisiana or any other state of soliciting for prostitution, pandering, letting premises for prostitution, contributing to the delinquency of juveniles, keeping a disorderly place, letting a disorderly place or dealing in narcotics? YES NO Have you had a license or permit to sell or deal in alcoholic beverages issued by the United States, this state or any other state revoked YES NO within 5 years prior to this application? Have you been convicted or had judgment against you involving alcoholic beverages by this state or any other state or the United States YES NO within 5 years prior to this application? Are you married? If yes, is your spouse eligible for a permit? Have you ever been convicted for violating YES NO YES NO any of the provisions of the liquor or beer YES NO laws of Louisiana? Do you or your spouse hold interest in any Has your spouse ever been denied or had Full name of spouse establishment holding a state retail permit? If an alcoholic beverage permit? YES NO yes, list. YES NO Trade Name Address Type interest % Equity Permit No. Sex Race Have you ever used any other name than NO the one given herein? YES Name used If yes, given details below. Place used Dates From to Is this application being made by you as a subterfuge to permit any person other than yourself to secure a permit from the Office of Alcohol YES NO and Tobacco Control in your name for his benefit? AFFIDAVIT This affidavit must be signed by owner, if individual ownership; authorized partner, if partnership or authorized official, if corporate partnership, it is understood any misstatement or suppression of fact in this application or accompanying documents is grounds for denial of permit. I swear (we swear) that I have read each of the questions in this application and that the answers which I have given are true and correct to the best of my knowledge and that I meet the qualifications and conditions set out in La. R.S. 26:79 and 279 and I further swear (or affirm) that I have no interest in any establishment holding a state retail beer or liquor permit other than the type applied for. Signature: ______________________________________________________________ Title: Print/Type your name: Sworn to and subscribed to me this In the parish of day of , 20 , State of Notary Public’s Signature: ________________________________________________ Print Name of Notary Public: American LegalNet, Inc. www.FormsWorkflow.com