APPLICATION FOR CHANGE IN MANAGER/ASSISTANT MANAGER INSTRUCTIONS Please read and follow these instructions carefully. A properly filed application will allow a determination of your eligibility to be made without undue delay 1. The owner, a partner, an officer, or an ABC approved general manager must complete, sign and have properly notarized page two (2) of this form. Note, if you are applying for a new position as General Manager, you can not sign this form. 2. The PERSONAL RECORD form must be completed by the person applying for approval as a manager/assistant manager. This form must be properly notarized. 3. A money order or cashier’s check in the amount of $27.00, made payable to ABC-FF, must be submitted with this application. NEITHER PERSONAL CHECKS NOR CHECKS DRAWN ON THE COMPANY ACCOUNT WILL BE ACCEPTED FOR THIS FEE. DO NOT SEND CASH. 4. The two (2) enclosed fingerprint cards, properly executed, must be submitted with the application. These cards may be completed by any qualified police officer or sheriff’s deputy. The cards must be legible and accurate and capable of being classified by the Federal Bureau of Investigation. You must also complete these cards with the proper information. 5. Your MISSISSIPPI STATE INCOME TAX filing status will be verified for the past three (3) years. THIS OFFICE ALSO REPORTS TO THE INTERNAL REVENUE SERVICE THAT YOU HAVE APPLIED FOR APPROVAL AS MANAGER. If you have failed to file your state or federal tax returns when due, you may contact the IRS and/or State Tax Commission office in your area for assistance. When you have filed all late returns and paid any taxes due, please request the State Tax Commission to contact our office at (601) 856-1330 to verify that your filing status is current so that processing of your application may continue. 6. You must complete the Waiver and Authorization to release section. This form must be signed, dated and witnessed by two (2) people. 7. If you need assistance, call ABC PERMIT DEPARTMENT at (601)-856-1330. 8. Mail your completed application to: Alcoholic Beverage Control Permit Department P.O. Box 540 Madison, Ms. 39130-0540 American LegalNet, Inc. www.FormsWorkflow.com ABCD 1001/MANAGER (REVISED 07/03) ABC PERMIT NUMBER MANAGER/ASSISTANT MANAGER I, , the sole owner, partner, officer, or general manager, do hereby request the Alcoholic Beverage Control to change &/or add the name of the manager &/or assistant manager as follows: FROM: Previous manager or asst. manager’s name: Name of ABC permitted business: Address: TO: New manager or asst. manager’s name: Home address: Social Security Number: I hereby certify that the reason for filing this requested change is: Date: Signature: Title: (Owner,Officer,Partner, or General Manager) State of County of NOTARY THIS DAY personally came and appeared before me, the undersigned authority in and for the aforesaid jurisdiction, the within named , who, after being by me first duly sworn, states on oath that the matters and things contained and set forth in the foregoing application are true and correct as stated therein. SWORN TO AND SUBSCRIBED before me, this the , day of Notary Public My commission expires: Page 2 American LegalNet, Inc. www.FormsWorkflow.com ABC PERMIT NUMBER PERSONAL RECORD MANAGER/ASSISTANT MANAGER 1. Name (last) (first) General Manager 2. Name of business 3. Date of Birth Driver’s License No. Height Weight Manager (middle) Assistant manager Social Security No. Age Hair Color Eye Color 4. Telephone No. (home) Sex Race (business) 5. List your residences for the past five (5) years, staring with current address. FROM TO ADDRESS CITY,STATE,ZIP CODE MO/YR MO/YR ______ ______ _______________________ _______________________ ______ ______ _______________________ _______________________ ______ ______ _______________________ _______________________ ______ ______ _______________________ _______________________ ______ ______ _______________________ _______________________ 6. List your employment or occupational history for the past five (5) years. FROM TO EMPLOYER CITY,STATE MO/YR MO/YR ______ ______ _______________________ _______________________ ______ ______ _______________________ _______________________ ______ ______ _______________________ _______________________ ______ ______ _______________________ _______________________ ______ ______ _______________________ _______________________ 7. Have you filed and paid your Mississippi State Income Taxes and your Federal Income Taxes?______, If “no”, explain ____________________ Page 3 American LegalNet, Inc. www.FormsWorkflow.com 8. Have you ever been convicted of any of the following: a. A felony, in any state, federal or military court? b. A violation of the Local Option ABC Laws, Rules & Regulations, or the Prohibition Laws In any state or local jurisdiction? c. A violation of any law relating to alcoholic beverages or beer such as DUI,DWI, or public drunk in any in any state or local jurisdiction? d. A violation of any drug related law? PERSONAL RECORD SUPPLEMENT ( IF “YES” TO A, B, C, OR D ABOVE, EXPLAIN FULLY) List convictions (specific charges) Date and jurisdiction of same APPLICANT’S SIGNATURE DATE NOTARY STATE OF COUNTY OF THIS DAY personally came and appeared before me, the undersigned authority in and for the aforesaid jurisdiction, the within named , who, after being by me first duly sworn, states on oath that the matters contained and set forth in the foregoing application are true and correct as stated therein. SWORN TO AND SUBSCRIBED before me, this the day of , Notary Public My commission expires: Page 4 American LegalNet, Inc. www.FormsWorkflow.com WAIVER AND AUTHORIZATION TO RELEASE INFORMATION TO WHOM IT MAY CONCERN: I authorize you to furnish the Alcoholic Beverage Control Division, State Tax Commission with any and all information that you may have concerning me, my work record, my reputation, and my military service records. You may allow inspection or records by, and copies of these records may be provided to, an authorized representative of the Alcoholic Beverage Control Division. Information of a confidential or privileged nature may be included. Your reply will be used by the Commission in determining my fitness and eligibility to be granted an Alcoholic Beverage Control Permit. A reproduction of this request by Xerox or similar process shall be for all intents and purposes as valid as the original. I hereby release you, your organization and others from liability or damages which may result from furnishing the information requested. Applicant’s Signature Date WITNESSES’ SIGNATURES Page 5 American LegalNet, Inc. www.FormsWorkflow.com American LegalNet, Inc. www.FormsWorkflow.com