Club Supplementary Questionnaire Rev 7 - 2016 Bureau of Alcoholic Beverages Division of Liquor Licensing & Enforcement 8 State House Station Augusta, ME 0433 3 - 0 008 Tel: (207) 624 - 7220 Fax: (207) 387 - 34 3 4 SU PPLEMENTARY QUESTIONNAIRE FOR CLUB APPLICANTS 1. Legal Club Name: 2. D/B/A Name: 3. Complete Title, name, date of birth and telephone number for each principal officer of the club: Title Name Birth Date Tel ephone 4 . Date Club was incorporated: 5 . Purpose of Club: Social Recreational Patriotic Fraternal 6 . Date regular meetings are held: 7 . Date of election of Club Officers: 8 . Date elected officers are installed: 9 . Total Membership: Annual Dues: Payable When: 10 . Does the Club cater to the public or to groups of non - members on the premises? Yes No 1 1 . Excluding salaries, will any person, other than the Club, receive any of the financial profits from the sales of liquors? Yes No 1 2 . If a manager or steward is employed, complete the following: Name: Date of Birth: Sign in blue ink Signat ure & Title of Club Officer Date Print Name & Title of Club Officer American LegalNet, Inc. www.FormsWorkFlow.com