Application for Change in Manager / Assistant Manager return to Alcoholic Beverage Control Division Permit Department P.O. Box 540 Madison, MS 39130-0540 1 American LegalNet, Inc. www.FormsWorkFlow.com Application Instructions Please read these instructions prior to completing this application for a change in officers of your private club permit. The owner, partner, officer, LLC managing member, or an ABC approved general manager must complete, sign and have page two (2) of this form notarized. The owner of the business must complete the section designating you as a manager. A money order or cashier's check in the amount of $32.00, made payable to "ABC-FF", must be submitted with this application. Do not send cash or personal checks. Each manager applicant must submit two (2) fingerprint cards with this application. The applicant must be fingerprinted by a law enforcement officer on ABC "Applicant" fingerprint cards. The cards must be complete, legible, and capable of being classified by the Federal Bureau of Investigation. Some law enforcement agencies have ABC fingerprint cards on hand. If you need fingerprint cards, contact the Permit Department or visit your local Department of Revenue District office. Your Mississippi Income Tax filing status, if applicable, will be verified for the past three (3) years. If records indicate that you are delinquent in filing these returns (or you are indebted to the State of Mississippi for any other taxes or fees), you will be notified and must obtain clearance from your local DOR District Office before we can continue processing your application. You must complete the Waiver and Authorization to release section. This form must be signed, dated and witnessed by two (2) people. If you need assistance, call the ABC Permit Department at (601)-856-1330. Mail your completed application to: Alcoholic Beverage Control Permit Department P.O. Box 540 Madison, MS 39130-0540 ABCD 1001/manager 2 American LegalNet, Inc. www.FormsWorkFlow.com (revised 08/2013) ABC Permit Number Manager / Assistant Manager I, , the sole owner, partner, officer, LLC managing member or general manager, request the Alcoholic Beverage Control to change and/or add the name of the manager and/or assistant manager as follows: From: Previous manager or assistant manager's name: Name of ABC permitted business: Address: To: New manager or assistant manager's name: Home address: Social Security Number: ___________________________________________ Signature of owner ______________________ Date Notary State of County of This day personally came and appeared before me, the undersigned authority in and for the aforesaid jurisdiction, ,who, after being by me first duly sworn, states on the within named 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 ABC permit number My commission expires: 3 American LegalNet, Inc. www.FormsWorkFlow.com Personal Record Manager / Assistant Manager 1. Name (last) (first) (middle) General Manager 2. Name of business Manager Assistant Manager 3. Date of birth________________________________ Social Security No.*__________________________ Driver's License No.__________________________ Age_______________________________________ Sex_______________________________________ 4. Telephone no. (home) Height_____________________________________ Weight____________________________________ Hair color__________________________________ Eye color__________________________________ Race______________________________________ (business) *This information is used for identification and in the administration of state tax laws. The Department is authorized to collect the information pursuant to 42 U.S.C. § 405(c)(2)(c)(i). Additionally, Mississippi law requires all applicants under Miss. Code Ann. §67-1-1 et seq. to provide Social Security Numbers. ( Miss. Code Ann. §67-1-53). Any applicant who refuses to provide the required information will be denied the permit. 5. List your residences for the past five (5) years, starting with current address. From Mo/Yr To Mo/Yr Address City, State, Zip Code ______ ______ ______ ______ ______ ______ ______ ______ _______________________ _______________________ _______________________ _______________________ ____________________________ ____________________________ ____________________________ ____________________________ 4 American LegalNet, Inc. www.FormsWorkFlow.com 6. List your employment or occupational history for the past five (5) years. From Mo/Yr ______ ______ ______ ______ ______ Yes To Mo/Yr Employer City, State _______________________ _______________________ _______________________ _______________________ ____________________________ ____________________________ ____________________________ ____________________________ ______ ______ ______ 7. Have you filed and paid (if applicable) your Mississippi Income Tax for the past three (3) years? No If no, explain: 8. Have you ever been convicted of any of the following: (answer each question) a. A felony in any state, federal or military court? Yes No b. A violation of the local option ABC laws, rules and regulations, or the prohibition laws in any state or local jurisdiction? Yes No c. A violation of any law relating to alcoholic beverages or beer? (for example: dui, sales of alcohol to a minor, public intoxication, or sale of alcohol to a visibility intoxicated person, etc.) Yes No d. A violation of any controlled substance related law? Yes No Date If you answered "yes" to 8a, 8b, 8c, or 8d, complete the following: Offense Jurisdiction (City, State) Disposition _______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 5 American LegalNet, Inc. www.FormsWorkFlow.com By signing this form, I agree that making a material misrepresentation on this application shall be evidence of a lack of trustworthiness as contemplated by Mississippi Code Ann. Section 67-1-57 and provides a basis for denial on this application. _______________________________________________ Applicant's Signature ___________________________ Date Notary State of _____________________ County of