APPLICATION, CHANGE IN CORPORATE NAME OF ABC PERMITTED BUSINESS RETURN TO ALCOHOLIC BEVERAGE CONTROL DIVISION PERMIT DEPARTMENT P. O. BOX 540 MADISON, MS 39130-0540 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION INSTRUCTIONS Please read these instructions prior to completing this application. The permit transfer fee is a non-refundable $25.00. If you currently must pay for your alcoholic beverages orders by certified funds, then you must submit certified funds for payment of this fee. NOTE: This form is not to be used to report and seek approval for any changes in ownership. This form is to be used when ownership remains the same, but the corporate entity itself has undergone a name change. In addition to this application, please include the following information: A) Include a copy of the filed documents with the Secretary of State's Office reflecting the amendment to your corporate name. B) Include proof that you have filed an updated sales tax registration form 70001 with the Department of Revenue to reflect the transfer in corporate name. Send your completed application to: ALCOHOLIC BEVERAGE CONTROL DIVISION PERMIT DEPARTMENT P. O. BOX 540 MADISON, MS 39130-0540 PLEASE ALLOW AMPLE TIME FOR PROCESSING If you need assistance, call the ABC Permit Department at 601-856-1330. American LegalNet, Inc. www.FormsWorkFlow.com (REV. 08/2013) PERMIT DEPT USE ONLY AMT OF CHECK CHECK NUMBER PERMIT NUMBER APPLICATION FOR TRANSFER IN CORPORATE NAME OF ALCOHOLIC BEVERAGE RETAILERS PERMIT I, , doing business as ABC Permit No. and located at (street) , change in corporate name to: doing business as: Telephone Number (business) I. hereby submit application for a (home) Does the applicant have, or has the applicant ever had, an interest in any other alcoholic beverage 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 If "yes" explain fully: Department? III. List your Mississippi Sales Tax Number: List your Federal Identification Number (EIN) ____________________________ IV. For corporations, list total amount of stock, common and preferred, and each officer, director, and 10% or greater stockholders below, along with their addresses. Attach additional sheets if necessary. Include a copy of the amended filing with the Secretary of State's Office reflecting the change in name. NAME TITLE ADDRESS AMT. SHARES American LegalNet, Inc. www.FormsWorkFlow.com V. For limited liability companies, please list all members, their addresses, and percentage of ownership. Please indicate managing member, if applicable. Include a copy of the amended filing with the Secretary of State's Office reflecting the change in name. NAME TITLE ADDRESS % OWNED VI. Have you filed an updated sales tax registration form 70-001 with the Department of Revenue to report the change in corporate name? ________ PERMITTEE CERTIFICATION I, ,certify under penalty of perjury that the organization applying for this Alcoholic Beverage Retailers Permit does meet the qualifications of a permittee as described in Sections 67-1-5, 67-1-51, 67-1-55, and 671-69, 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 thereby. 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. SIGNATURE DATE NOTARY SWORN TO AND SUBSCRIBED before me, this the day of , . ________________________________ NOTARY PUBLIC My commission expires:__________________ 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 fee payment for this transfer? Completed the application? Included a copy of the amendment that you filed with the Secretary of State's Office to effect the name change in name? Completed the permittee certification? Filed an updated sales tax registration form 70-001 with the Department of Revenue to report the change in corporate name? American LegalNet, Inc. www.FormsWorkFlow.com