Minnesota Department of Public Safety ALCOHOL AND GAMBLING ENFORCEMENT DIVISION Print Form 444 Cedar Street, Suite 222, St. Paul, MN 55101 (651) 201-7506 TDD (651) 282-6555 FAX (651) 297-5259 APPLICATION FOR LICENSE TO SELL INTOXICATING OR 3.2 % MALT LIQUOR ON A COMMON CARRIER AND/OR OPTIONAL 2 A.M. CLOSING LICENSE INTOXICATING (INCLUDES 3.2% MALT LIQUOR) LIQUOR ($250 plus $25 OET* surcharge) 3.2% MALT LIQUOR ONLY ($50 plus $5 OET* surcharge) SUNDAY INTOXICATING LIQUOR ($75 plus $7.50 OET* surcharge) License Expiration Date: $275 $55 $82.50 DUPLICATE LICENSE ($30 plus $5 OET* surcharge) DUPLICATE LICENSE ($20 plus $5 OET* surcharge) DUPLICATE LICENSE ($30 plus $5 OET* surcharge) License Number: $35 Each $25 Each $35 Each Date Approved: Workers Comp. Ins, Co. Policy Number Federal Tax ID Number Policy Period CARRIER'S NAME LICENSE PERIOD FROM TO APPLICANT'S NAME AND TITLE BUSINESS PHONE MAIN ADDRESS OF CARRIER FAX NUMBER CITY STATE ZIP CODE If this application is for a common carrier (plane, boat, railroad car, etc.) commencing operations in Minnesota for the first time, give the date operations will begin. An intoxicating liquor, 3.2% malt liquor and/or Sunday license is required for the first carrier to be operated in Minnesota. For each additional carrier a duplicate intoxicating, 3.2% malt liquor and/or Sunday license is required. Give the total number of carriers requiring intoxicating, 3.2% malt liquor or duplicate intoxicating liquor licenses. Give the total number of carriers requiring Sunday intoxicating, 3.2% malt liquor or duplicate Sunday intoxicating liquor licenses. All statements and documents submitted with this application shall become a permanent part of the record. The Liquor Control Director has the right to reject or revoke any license or license application containing a false statement. All records pertaining to purchase and sales shall be kept at the company's main office for a period of four years. Applicants applying for Optional 2 AM closing license, complete the following steps: Yes No 1. Does your liquor license issuing authority allow the sale of alcoholic beverages until 2 AM? (If Yes, Continue) 2. Report your previous 12 months total intoxicating liquor receipts by checking one of the following: Up to $100,000 in gross annual receipts for intoxicating liquor $300 2 AM license fee Over $100,000 but not over $500,000 in gross annual receipts for intoxicating liquor $750 Over $500,000 in gross annual receipts for intoxicating liquor $1,000 2 AM license fee Did not sell intoxicating liquor for a full 12 months prior to this application $200 Print Full Name of Applicant and Title Signature of Applicant 2 AM license fee 2 AM license fee DOB SSN Date MAKE CHECK PAYABLE TO: DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT * Office of Enterprise Technology AMOUNT RECEIVED American LegalNet, Inc. www.FormsWorkFlow.com