Minnesota Department of Public Safety Alcohol and Gambling Enforcement Division (AGED) 444 Cedar Street, Suite 133, St. Paul, MN 55101-5133 Telephone 651-201-7507 Fax 651-297-5259 TTY 651-282-6555 www.dps.state.mn.us Application for Optional 2 AM Liquor License License type code: 2AM License Expiration Date________________ (For Office Use Only) ID#________________ Licensee Name: _______________________________________________________________________________ Trade Name: __________________________________________________________________________________ Licensed Location Address: ______________________________________________________________________ City, State, Zip Code: ___________________________________________________________________________ Business Phone: _______________________________________________________________________________ If the above named licensee is a corporation, partnership, or LLC, complete the following for each partner/officer: __________________________________________________________________________________________________________________ Partner/Officer Name (First Middle Last) DOB Social Security # Home Address ________________________________________________________________________________________________________________________ Partner/Officer Name (First Middle Last) DOB Social Security # Home Address ________________________________________________________________________________________________________________________ Partner/Officer Name (First Middle Last) DOB Social Security # Home Address Licensee must report previous 12 month on sale alcoholic beverage gross receipts by checking one of the boxes below. Next to the box you check is your 2 AM license fee. Make check payable to: Alcohol and Gambling Enforcement Division (AGED). Mail this application and check to : AGED, 444 Cedar St., Suite 133, St. Paul, MN 55101-5133. $300 2 AM license fee $750 2 AM license fee $1,000 2 AM license fee $200 2 AM license fee $200 2 AM license fee Up to $100,000 in on sale gross receipts for alcoholic beverages Over $100,000, but not over $500,000 in on sale gross receipts for alcoholic beverages Over $500,000 in on sale gross receipts for alcoholic beverages 3.2% On Sale Malt Liquor licensees or Set Up license holders Did not sell alcoholic beverages for a full 12 months prior to this application Yes No Does your city or county licensing official allow the sale of alcoholic beverages until 2 AM? City Clerk/County Auditor Signature_______________________________________ Date________________ (I certify that the city or county of _____________________________ approves the sale of alcoholic beverages until 2 AM) Licensee Minnesota Tax ID Number (Required)______________________________________ Licensee Signature______________________________________________________ Date________________ (I certify that I have answered the above questions truthfully and correctly) Licensee: Prior to submitting this application to the Alcohol and Gambling Enforcement Division, it must be signed by your local city or county licensing official. American LegalNet, Inc. www.FormsWorkflow.com (2AM-5/06)