BUREAU USE ONLY Department of Public Safety Liquor Licensing & Inspection Division License No. Assigned: Class: Deposit Date: Promise by any person that he or she can expedite a liquor license through influence should be completely disregarded. To avoid possible financial loss an applicant, or prospective applicant, should consult with the Division before making any substantial investment in an establishment that now is, or may be, attended by a liquor license. Amt. Deposited: PRESENT LICENSE EXPIRES ________________ Off-Premise Retailer – Malt Liquor ............................................................................................................. $200.00 Off-Premise Retailer – Table Wine ............................................................................................................ $200.00 Filing Fee ................................................................................................................................................. $ 10.00 NOTE: If the place of business is located in an unincorporated place, the application must be approved by the County Commissioners. All such applications shall be accompanied by receipt of payment of the $10.00 filing fee to the County Treasurer. Check Payable: Treasurer State of Maine ALL QUESTIONS MUST BE ANSWERED IN FULL 1. APPLICANT(S) –(So le Proprietor, Corporation, Limited Liability Co., 2. Business Name (D/B/A) etc.) DOB: DOB: Location (Street Address) DOB: Address City/Town State Zip Code State Zip Code Mailing Address City/Town State Telephone Number Zip Code Fax Number City/Town Business Telephone Number Federal I.D. # Fax Number Seller Certificate # 3. List of Wholesale Value and Types of Merchandise in inventory: (Must be answered) Edible Foods $ __________ Tobacco Products $ __________ Greeting Cards, Magazines, Newspapers $ __________ Paper Goods $ __________ Total of all other merchandise in inventory $ __________ 4. Is applicant a Corporation, Limited Liability Co. or Limited Partnership: Yes ? No ? (If Yes complete Supplementary Questionnaire) 5. If manager is to be employed, give name: _____________________________________________________________ 6. If business is NEW indicate opening date: _________________ Business Hours: ___________________________ 7. Is/Are applicant(s) citizens of the United States? Yes ? No ? 8. Is/Are applicant(s) residents of the State of Maine? Yes ? No ? 164 State House Station Augusta ME 04333-0164 Tel: (207) 624-7220 OffPremRetailApp / 2003 Fax: (207) 287-3424 American LegalNet, Inc. www.FormsWorkflow.com 9. List name, date of birth, place of birth for all applicants and managers. Give maiden name, if married: Name in Full (Print Clearly) DOB Place of Birth Residence address on all of the above for previous 5 years (Limit answer to city & state) ____________________________________________________________________________________________________________________________________ Use a separate sheet of paper if necessary. 10. Has applicant(s) or manager(s) ever been convicted of any violation of the law, other then minor traffic violations of any State of the United States? Yes ? No ? Name: ______________________________________________ Date of Conviction: ________________________ Offense: ____________________________________________ Location: ________________________________ Disposition: _________________________________________ 11. Will any law enforcement official benefit financially either directly or indirectly in our license, if issued? Yes ? No ? If Yes, give name: _____________________________________________________________ 12. Has applicant(s) formerly held a Maine liquor license? 13. Do applicant(s) own the premises? Yes ? No ? Yes ? No ? If No, give name and address of owner: __________________ _______________________________________________________________________________________________ 14. Describe in detail where liquor will be stored: (Supplemental On/Off Premise Diagram Required)________________ _______________________________________________________________________________________________ 15. Have you received any assistance financially or otherwise (including any mortgages) from any source other than yourself in the establishment of your business? Yes ? No ? If Yes, give details: __________________________ _______________________________________________________________________________________________ 16. Does any other person have any interest directly or indirectly in your business? Yes ? No ? If Yes, give details: ____________________________________________________________________________________________ PAYMENTS TO THE DEPARTMENT OF PUBLIC SAFETY, LIQUOR LICENSING & INSPECTION DIVISION BY CHECK SUBJECT TO PENALTY PROVIDED BY SECTION 3 OF TITLE 28A, MAINE REVISED STATUTES NOTE: “I understand that false statements made on this form are punishable by law. Knowingly supplying false information on this form is a Class D offense under the Criminal Code, punishable by confinement of up to one year or by monetary fine of up to $500.00 or by both.” Dated at: _____________________________________________ on _____________________________, 20 ________ City/Town Date Year ____________________________________________ _____________________________________________ ____________________________________________ Signature(s) of Applicant(s) or Corporate Officer(s) _____________________________________________ Print Name of Applicant(s) or Corporate Officer(s) 164 State House Station Augusta ME 04333-0164 Tel: (207) 624-7220 OffPremRetailApp / 2003 Fax: (207) 287-3424 American LegalNet, Inc. www.FormsWorkflow.com