TOWN OF ____________________ ................................20__ TO THE LICENSING BOARD The undersigned licensee.......................................................................................................................................................................................................... respectfully petitions for the transfer of the ....................................................................................................................................................................... (Class of License) beverages license now exercised by the said licensee on the premises located at ...................................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................................... whose address is ...................................................................................................................................................................................................................... (If present licensee is a corporation, fill in the following paragraph) The said licensee is a corporation duly organized under the laws of the Commonwealth of Massachusetts, and its officers, directors and stockholders, their residences, and shares owned by each are as follows: (NAME) (ADDRESS) (SHARES) FROM: (PLACE AN * BEFORE THE NAME OF EACH DIRECTOR.) .........................................(president) ......................................................................................... ............................ .........................................(treasurer) ......................................................................................... ............................ ...............................................(clerk) ........................................................................................ ............................ ....................................................... ........................................................................................ ........................... ....................................................... ........................................................................................ ........................... (If proposed transferee is a corporation, fill in the following paragraph.) The proposed transferee is a corporation duly organized under the laws of said Commonwealth and having a usual place of business in said .............................., and its officers and stockholders, their residences, and shares owned by each are as follows: (NAME) (ADDRESS) (SHARES) TO: (PLACE AN * BEFORE THE NAME OF EACH DIRECTOR.) ..............................................(president) ........................................................................................ ........................... ..............................................(treasurer) ........................................................................................ ........................... .....................................................(clerk) ........................................................................................ ........................... .............................................................. ........................................................................................ ........................... ............................................................. ........................................................................................ ........................... ............................................................. ........................................................................................ ........................... The above named proposed transferee hereby joins in this petition for transfer of said license, and respectfully petitions the Board to grant such transfer. SIGNATURE OF LICENSEE................................................................................................................................................................................................. (If a corporation, by its authorized representative) SIGNATURE OF PROPOSED TRANSFEREE............................................................................................................................................................................. (If a corporation, by its authorized representative) FORM 983 American LegalNet, Inc. www.FormsWorkflow.com