120606 FOR OFFICE USE ONLY Permit Number: State of Louisiana Office of Alcohol and Tobacco Control 8549 United Plaza Blvd, Suite 220 P.O. Box 66404 Baton Rouge, LA 70896-6404 Telephone (225) 925-4041 · Fax (225) 925-3975 Sequence Number: Wholesaler Schedule A 1. Applicant’s Name (individual, partnership, corporation, LLC): 2. Trade Name of Business (if applicable): 3. Location Address of Applicant (street/city/state/zip): 4. Name of person to be certified (Enter Full Legal Name): 5. Daytime Phone #: ( ) - 6. Residence Address (street/city/state/zip): 7. Race: 8. Sex: 12. Place of birth? 9. Date of Birth: 10. Social Security Number: 13. Are you a citizen of the United States? 11. Driver’s License # and State: 14. Naturalization Number (if applicable) Yes No 15. Are you a citizen of Louisiana? Yes No 16. Have you continuously resided in Louisiana for the past two years? 17. Are you married? Yes No If yes, provide full name, Social Security Number and Date of Birth of Spouse. Yes No 18. Do you, your spouse, any individual, any corporation, or any other party associated with this business hold any interest in any manufacturing or retail alcohol permit? Yes No If yes, answer the following questions in this section (provide attachment if necessary). 18a. Owner Name of business: 18b. Trade Name of Business: 18c. Permit Number: 18d. Location Address: 18e. Class and Type: 18f. Type of Interest: 18g. Equity Interest Held (provide attachment if necessary): 19. Have you or your spouse ever been convicted of a felony? Yes No If yes, complete Schedule “F” as provided by this office. 20. Have you or your spouse ever been convicted of violating any liquor or beer regulatory statute or rule? Yes No 21. Have you or your spouse ever been convicted of solicitation for prostitution, pandering, letting premises for prostitution, contributing to the delinquency Yes No of a juvenile, keeping a disorderly place, or dealing in narcotics? 22. Have you of your spouse had a license or permit to sell or deal in alcoholic beverages revoked within the last two years prior to the filing of this No schedule? Yes 23. Have you or your spouse ever been denied an alcoholic beverage permit? Yes No 24. If the response to Questions 19 and 21 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 20, 22, and 23 is “yes,” state the offense, date, and location. Apply attachments if necessary. 25. 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 26. Are you employed by the State of Louisiana? Yes No If yes, enter the name of the department. 27. 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 Misstatement or suppression of material facts in this application is grounds for denial of this permit. Conviction of filing false public records, a violation of Louisiana Revised Statute 14:133, may result in imprisonment for not more than five years with or without hard labor and fines of not more than $5000.00 (five thousand dollars), or both. 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