ABCD 1000T2 (Revised 8/95) APPLICATION and AFFIDAVIT CLASS II TEMPORARY RETAILERS PERMIT RETURN TO ALCOHOLIC BEVERAGE CONTROL PERMIT DEPARTMENT P.O. BOX 540 MADISON, MS. 39130-0540 American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS FOR PROPER FILING OF YOUR APPLICATION PLEASE READ PRIOR TO COMPLETING THIS FORM 1. An application fee of $75.00, in the form of either a cashier’s check or a money order payable to the Alcoholic Beverage Control must be returned with this completed application. 2. The applicant’s signature must be notarized by a licensed Notary Public. 3. The PRESENT OWNER must complete the affidavit authorizing the issuance of a Class II Temporary Permit for the licensed business. 4. If the existing permit is due to expire within 70 days of issue of a Class II Temporary Permit, then an application for renewal of that permit must be submitted along with this form. 5. Submit either an original application for a sales tax number (green form) or a copy of the sales tax application along with this form. A temporary permit will not be issued without proof of application for a sales tax number. 6. After this temporary permit is issued, you have fourteen (14) days to submit a completed application for transfer of the permanent permit. Your failure to submit a completed transfer application and other information required by ABC Regulations Nos. 45 & 47 within 14 days will void the Class II Temporary Retailers Permit. 7. This permit expires seventy (70) days after issue. NOTICE: ALL NEW PERMITTEES DURING THEIR FIRST 90 DAYS ARE ON "CERTIFIED FUNDS" STATUS. ORDERS FOR ALCOHOLIC BEVERAGES MUST BE PAID WITH A MONEY ORDER OR A CERTIFIED CHECK FOR THE AMOUNT OF PURCHASE AND ANY FEES DUE. NEITHER PERSONAL CHECKS NOR COMPANY CHECKS ARE ACCEPTABLE. CASH IS ACCEPTED ONLY IF DELIVERED IN PERSON. BRING EXACT AMOUNT DUE, CHANGE IS NOT AVAILABLE. American LegalNet, Inc. www.FormsWorkflow.com AFFIDAVIT and APPLICATION, CLASS II TEMPORARY PERMIT AFFIDAVIT AUTHORIZING TRANSFER I, _________________________________________ , doing business as ____________________________________ , ABC Permit No. _____________ hereby authorize the Alcoholic Beverage Control to issue a Class II Temporary Retailers Permit to _________________________________________________ doing business as _________________________________________________ effective ___________________________________ . ________________________________ (present owner’s signature) APPLICATION FOR CLASS II TEMPORARY PERMIT I. APPLICANT: _______________________________________________ (name of sole owner, partnership, or corporation) ADDRESS: __________________________________________ (street/post office box) II. (city) (state) (zip) BUSINESS: ________________________________________________ (trade name) ADDRESS: ___________________________________________ (street) (city) (zip) COUNTY: ____________ TELEPHONE No. (b.) _____________ (h.) ____________ III. IV. TYPE OF APPLICANT ENTITY: ( ) Sole Owner ( ) Partnership ( ) Trust ( ) Corporation ( ) Other ___________________ Have you or any member of your partnership or association, or any officer, director, or majority stockholder of your corporation, ever been convicted of any of the following: a felony regardless of its nature in any state or federal court, a violation of the Local Option Alcoholic Beverage Control Laws, or violation of any other law relating to alcoholic beverages, beer or light wine? ______________ If "yes", explain fully: _________ __________________________________________________________ __________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com PERMITTEE CERTIFICATION AND OATH I, ______________________________________, certify under penalty of perjury that the organization applying for this Temporary Class II Permit does meet the qualifications of Sections 67-1-51(l), (m), (n), (o), (p) or (q), 67-1-37, 671-51 (2) and (3), 67-1-55, 67-1-57 and 67-1-59. I affirm that this organization, in the exercise of this permit, will comply with the Local Option Alcoholic Beverage Control Laws, Rules and Regulations, relative to the purchase, sale, and handling of alcoholic beverages and will keep all records and make all reports and remittances as required thereby. I certify that the information presented on the application to be true and correct, to the best of my knowledge and belief. BY: _________________________________ TITLE: _______________________________ DATE: _______________________ NOTARY State of __________________ County of _________________ THIS DAY personally appeared before me, the undersigned authority in and for the county and state aforesaid, the within named __________________ with, after being duly sworn states on oath that the matters and things contained and set forth in the foregoing application are true and correct as stated. Sworn to and subscribed before me, this the ___ day of ___________, 19___. _______________________________ Notary Public My commission expires: ____________________ American LegalNet, Inc. www.FormsWorkflow.com