APPLICATION, CHANGE IN LOCATION OF ABC PERMITTED BUSINESS ALCOHOLIC BEVERAGE CONTROL PERMIT DEPARTMENT P.O. BOX 540 MADISON, MS 39130-0540 RETURN TO American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION INSTRUCTIONS Please read these instructions carefully prior to completing this application for transfer in location of your permit. The permit fee for this transfer is a non-refundable $25.00. If you currently must pay for your alcoholic beverage orders by certified funds, then you must submit certified funds for payment of this fee. All transfers in location must be approved by the Department before the move is actually made. This application may only be used if you are moving your business to a new location inside the same municipality. If you are moving to a new municipality, you must make application for a new permit. In addition to completing this application, we need the following information: A) floor plan of your new location B) a copy of your new lease or deed C) Proof of Publication ­ Publisher's Affidavit D) Proof that you have filed an updated sales tax registration, form 70001 with the Department of Revenue to report the change in location. Please review your application to be sure that you have completed it properly. Return your application to: ALCOHOLIC BEVERAGE CONTROL PERMIT DEPARTMENT P.O. BOX 540 MADISON, MS 39130-0540 PLEASE ALLOW AMPLE TIME FOR PROCESSING If you need assistance, call ABC Permit Department at (601) 856-1330. American LegalNet, Inc. www.FormsWorkFlow.com (REVISED 08/2013) PERMIT DEPT. USE ONLY AMT. OF CHECK CHECK NUMBER PERMIT NUMBER APPLICATION FOR CHANGE IN LOCATION OF ALCOHOLIC BEVERAGE RETAILER'S PERMIT I, ,doing business as , ABC Permit No. and located at (street) (city) (street) (county) submit an application for a change in location to: (county) _____ . (home) Telephone Numbers: (business) I. Does applicant, have or has the applicant ever had, an interest in any other alcoholic beverage retailer's permit? If "yes" explain fully: II. Is the applicant indebted to the State of Mississippi for any taxes, fees or payment of penalties imposed by law or by any rule or regulation of the Department? If "yes" explain fully: III. IV. V. List your Mississippi Sales Tax Number: List your Federal Identification Number (EIN)______________________________ Have you filed an updated sales tax registration, form 70-001, with the Department of Revenue to report the change in location? __________________ American LegalNet, Inc. www.FormsWorkFlow.com PERMITTEE CERTIFICATION AND OATH I, , certify under penalty of perjury that the organization applying for this Alcoholic Beverage Retailer's Permit does meet the qualifications of a permittee as described in Sections 67-1-5, 67-1-51, 67-1-55, and 67-1-69, of the Mississippi Code of 1972, Annotated. I affirm that this organization will comply fully with the provisions of the Local Option Alcoholic Beverage Control Laws, Rules and Regulations in the purchase, sale, and handling of alcoholic beverages and will keep all records and make all reports and remittances as required hereby. I certify that the information presented on this application to be true and correct, to the best of my knowledge and belief. I also agree that making a material misrepresentation on this application shall be evidence of a lack of trustworthiness as contemplated by MS Code Ann. Section 67-1-57 and provide a basis for denial on this application. (applicant's signature) Date: (title) SWORN TO AND SUBSCRIBED before me, this the ___________________ Notary Public day of , My Commission Expires: American LegalNet, Inc. www.FormsWorkFlow.com LEGAL NOTICE FORMAT FOR PUBLICATION OF A CHANGE IN LOCATION () () () () () I, I, the trustee for We, the partners of We, the officers of We, the members of (sole owner's name) (name of trust) (partnership name) (corporate name) (limited liability company name) intend to make application for a change in location of: ( ( ( ( ( ( ( ( ( ( ( ( ( ( ) ) ) ) ) ) ) ) ) ) ) ) ) ) a Mfr's permit Class I, distiller's &/or rectifier's permit a Mfr's permit Class II, wine manufacturer's permit a Mfr's permit Class III, native wine manufacturer's permit a Native wine retailer's permit a Package retailer's permit an On-premise retailer's permit an On-premise retailer's permit for wine only an On-premise retailer's permit for clubs a Common Carrier permit a Caterer's permit, for on-premise retailer permit holders a Caterer's permit a Solicitor's permit a Research permit an Alcohol processor permit Under the provisions of the Local Option Alcoholic Beverage Control Laws 67-1-1 et. seq., Mississippi Code of 1972. If granted a change from (name of corporation, trust, llc, partnership, or sole owner) doing business as , who is now operating at , propose to operate under the tradename of (I) (current business address) at (We) (street number) (street) of (county) The name(s), title(s), and address(es) of the owner(s)/(partner(s)/corporate officer(s)/member(s) and/or majority stockholder(s) of the above names business are If any person wishes to request a hearing to object to the issuance of this permit a request for a hearing must be made in writing and received by the Department of American LegalNet, Inc. www.FormsWorkFlow.com Revenue within (15) fifteen days from the first date this notice was published. Requests shall be sent to: Chief Counsel, Legal Division Department of Revenue P. O. Box 22828 Jackson, MS 39225 Date of First Publication: __/__/__ This the day of ,____________. American LegalNet, Inc. www.FormsWorkFlow.com NOTICE Your permit & packet will be mailed immediately after approval. If you elect to pick up your permit at the Liquor Distribution Center, call the Permit Department at 601-856-1330 to make prior arrangements. APPLICATION CHECK LIST Have you: Included the correct permit fee? Included a copy of your new floor plan? Included a copy of your new lease or deed? Included Proof of Publication of your legal notice? Completed your application, signed and had notarized? Filed an updated sales tax registration Form 70-001 with the Department of Revenue to report the change in location? American LegalNet, Inc. www.FormsWorkFlow.com