APPLICATION, TRANSFER ALCOHOLIC BEVERAGE PERMIT RETURN TO ALCOHOLIC BEVERAGE CONTROL DIVISION 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 for an alcoholic beverage retailer’s permit. These instructions, along with information printed on certain forms, if followed, will allow you to file a complete document thus reducing the amount of processing time required to determine your eligibility to hold an ABC permit. Each applicant, regardless of the type of ABC permit sought, must meet the statutory qualifications set by the Local Option Alcoholic Beverage Control Laws, Title 67, 1972 MCA. The Commission under authority of these laws has established policies requiring applicants to file certain documents concerning the applicant’s place of business. This application asks for particular information concerning each applicant to allow the Commission to determine the eligibility of the applicant for permitting as well as the suitability of the business premises to offer for sale alcoholic beverages. This application may be typed or neatly printed in ink. Include with your application a $25.00 non-refundable processing fee. First, complete the APPLICATION FOR TRANSSFER. This form is completed by the present permittee, along with the new applicant. The present permittee signs and has notarized the top portion of this form. The new applicant signs and has notarized the bottom portion of this form. (Note: This transfer will not be approved unless this form is completed by both parties) Then complete the appropriate SUPPLEMENTAL INFORMATION portion of the application for the permit type (whether package store, on-premises, or on-premises club etc) desired. (NOTE: An on-premises club is a chartered organization formed for the purpose other than the sale of alcoholic beverages. Examples of qualified clubs are Racket Clubs, Country Clubs, service clubs such as Veterans of Foreign Wars, etc). Then, complete the STATEMENT OF OWNERSHIP. Locate on this form the ownership classification of the applicant, whether a sole owner, partnership, corporation, trust, or other. This form contains instructions on who must file qualifying documents (PERSONAL RECORD FORM, Form 1001; SUMMARY FINANCIAL STATEMENT, Form 2007; and fingerprint cards) with this application. Note that partnerships and corporations must also file a separate SUMMARY FINANCIAL STATEMENT listing the business financial status. If you have out of state banks, then a BANK CONFIRMATION Form will be required. Contact this office if these forms are not attached to your application. The most common error made on this form is that it must be witnessed by two (2) people. ABC collects a pass- a-long $27.00 fee for fingerprint card processing by the Federal Bureau of Investigation. This fee is due payable with the application submission. This fee is in the forms of a Cashier’s Check or Money Order, payable to ABC-FF. Signatures on each PERSONAL RECORD form must be notarized and the waiver portion WITNESSED by two (2) people. The SUMMARY FINANCIAL STATEMENT form must be completed and witnessed by two (2) people along with the Waiver portion of this form. Four (4) PERSONAL RECORD FORMS and Five (5) SUMMARY FINANCIAL STATEMENT FORMS as well as eight (8) FINGERPRINT CARDS are included in this application packet. These prints must be taken by a qualified police officer. Contact ABC Permit Department if you need additional forms. Be sure to complete the PERMITTEE CERTIFICATION AND OATH ending this portion of the application. Next, complete the WAIVER AND AUTHORIZATION TO RELEASE INFORMATION. This release will assist us in verifying the information on your application. This form must be witnessed by two (2) people. American LegalNet, Inc. www.FormsWorkflow.com You must submit with this application a copy of your lease, if leasing the business premises, or your deed, if you own the business premises. If a lease, the leasee must be the applicant for the alcoholic beverage permit (sole owner, partnership, corporation) and the lease must not expire for at least twelve (12) months. Include also, a FLOOR PLAN of the business premises. Each applicant, for an alcoholic beverage permit is required to post a $5,000.00 BOND. This bond may be a Surety Bond, a Cash Bond, or an approved Certificate of Deposit. This packet contains a Surety Bond for your insurance company to complete for proof of issue. The bond must be issued in the APPLICANT’S NAME (name of sole owner, partnership, corporation or trust). NATIVE WINE MANUFACTURER APPLICANTS MUST USE THE NATIVE WINE SURETY BOND FORM. Please contact the ABC Permit Department for forms and instructions if you post either a cash bond or certificate of deposit in lieu of a surety bond. You are required to publish notice of your application in two (2) consecutive issues of the newspaper published in the town in which the business is located. If no local newspaper exists, the notice may be published in the newspaper produced in the town located nearest your business and within the same county. The notice must be published in its entirety in TEN POINT BOLD FACE type. An acceptable legal notice format is included in this packet. Submit with this application a PUBLISHER’S AFFIDAVIT (obtained from the newspaper) as proof of publication. You must apply for, and furnish with this application proof of application for a Federal Special Tax Stamp. Form #ATF F 5630.5 (10-99) is provided in this packet. Include a copy of this application and payment (canceled check or receipt) as proof of application. If you have questions, or need assistance, call the Bureau of Alcohol Tobacco and Firearms at 601-965-4205 (within Mississippi) or 1-800-937-8864 (outside Mississippi). You must register with the State Tax Commission and obtain a sales tax number. An application is included in this packet. You may return this form with your application. Last, review the application check list. Be sure to include proper payment for the permit, and send the completed forms to: ALCOHOLIC BEVERAGE CONTROL PERMIT DEPARTMENT P O BOX 540 MADISON, MS 39130-0540 Please allow four to six weeks for processing of your application. If you need assistance, call ABC Permit Department at 601-856-1330 American LegalNet, Inc. www.FormsWorkflow.com APPLICATION FOR TRANSFER OF ALCOHOLIC BEVERAGE RETAILER’S PERMIT I, a , doing business as package retailer on premise retailer holding ABC Retailers Permit No. and located at (street) (city) (county) hereby submit application to transfer this permit for change in ownership to: NAME DOING BUSINESS AS ADDRESS I certify under penalty of perjury that the information presented is true and correct to the best of my knowledge. I further certify that (indicate one) I retain full ownership and control of this business and will continue to do so until this transfer is approved by the Commission. A Class II Temporary Permit has been issued to the applicant for transfer of this permit. SIGNATURE DATE ___PRESENT OWNER ___PARTNER ___PRESIDENT OF CORPORATION STATEMENT OF TRANSFEREE I, applicant for transfer of the Alcoholic Beverage Retailers Permit described above recognize that the renewal privilege upon expiration of this permit may not be construed as a vested right. I understand that, if this is an on-premises permit, I assume responsibility for payment of any Additional Privilege Fees due on alcoholic beverage purchases made by the current permit holder. I certify under penalty of perjury that the information presented is true and correct to the best of my knowledge. I further certify that (indicate one) A Class II Temporary Retailer’s Permit has been issued me for this business. I exercise no control over nor have any financial interest in the business at this time nor will I have any such control or interest in the business until the Commission approves this application. SIGNATURE TITLE DATE NOTARY STATE OF COUNTY OF THIS DAY personally appeared before me, the undersigned authority in and for the jurisdiction aforesaid, the within named and who, after being duly sworn states on oath that the matters and things contained herein are true and correct. SIGNATURES AND SWORN TO AND SUBSCRIBED before me, this the My commission expires: day of , NOTARY PUBLIC American LegalNet, Inc. www.FormsWorkflow.com (REVISED7/01) PERMIT DEPT USE ONLY AMT OF CHECK CHECK NUMBER PERMIT NUMBER TRANSFER APPLICATION ALCOHOLIC BEVERAGE RETAILERS PERMIT I. APPLICANT: (NAME OF SOLE OWNER, PARTNERSHIP,CORPORATION OR TRUST) Tradename: Mailing Address: (street/p.o.box) (city) (state) (zip) Location of business (street) This location is (city) inside (zip) outside the corporate city limits. Include a copy of the lease or deed to the business premises and submit a new floor plan of the Premises . (see instructions) Telephone Number(business) (home) II. TYPE OF ORGANIZATION III. Does the applicant have, or has the applicant ever had, an interest in any other alcoholic beverage retailer’s permit? If “yes”, explain fully: IV. 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 Commission? If “yes”, explain fully: V. List your Mississippi Sales Tax Number: VI. List your Federal Special Tax Stamp Number: Have you ever been denied a Special Tax Stamp? VIII. ( ) Sole Owner ( ) Corporation ( ) Other ( ) Partnership ( ) Trust . If “yes”, explain fully: List the company issuing your ABC Retailer’s Bond: American LegalNet, Inc. www.FormsWorkflow.com SUPPLEMENTAL INFORMATION CATERER’S PERMIT APPLICANTS ONLY Complete this section in addition to STATEMENT OF OWNERSHIP I. Include a copy of the health certificate issued by the State Department of Health. List the certificate number: II. Does the applicant understand that ten (10) days prior to each catered event, written notice of such event must be supplied to the Alcoholic Beverage Control? (Contact ABC for forms used for this notification. SUPPLEMENTAL INFORMATION PACKAGE RETAILER APPLICANTS ONLY Complete this section in addition to STATEMENT OF OWNERSHIP I. Is the applicant, if an individual, or a partnership, each of its partners, a legal resident of the State of Mississippi? II. Is the applicant a corporation? If “yes”, is the designated manager a legal resident of Mississippi? NOTE: Managers require Commission approval. Contact the ABC Permit Department for an application. SUPPLEMENTAL INFORMATION ON-PREMISE PERMIT APPLICANTS ONLY NOTE: Hotel, motel, bed-and-breakfast inns, restaurants and similar applicants must complete SECTION I, in addition to the STATEMENT OF OWNERSHIP SECTION I A. Name of business B. Type of business hotel/motel (If hotel/motel, number of rooms C. restaurant other Population of city General Manager Home address (street/p.o.box) D. (city) (state) (zip) (city) (state) (zip) Restaurant Manager Home address (street/p.o. box) E, Beverage Sales Manager Home address (street/p.o.box) (city) (state) (zip) F. Does the hotel / motel or restaurant described in this application meet the statutory definition of same as found in S.67-1-5, (I), or (m), MCA (1972)? If “no”, explain fully: American LegalNet, Inc. www.FormsWorkflow.com STATEMENT OF OWNERSHIP ALCOHOLIC BEVERAGE RETAILER PERMIT APPLICATION I. Name of business II. Will this business be operated as a sole ownership by the person applying for this permit? If “yes”, submit a PERSONAL RECORD (form 1001) a SUMMARY FINANCIAL STATEMENT (form 2007), and two (2) properly executed fingerprint cards with a certified check for $27.00 made payable to ABC-FF with this application. III. Will this business be operated as a partnership? If “yes”, list each partner’s name and extent of this interest in the partnership. NAME HOME ADDRESS AMT OF INTEREST OWNED Note: Each partner must submit a PERSONAL RECORD (form 1001), a SUMMARY FINANCIAL STATEMENT(form 2007),and two (2) properly executed fingerprint cards with a certified check for $27.00 made payable to ABC-FF with this application. A separate SUMMARY FINANCIAL STATEMENT (Form 2007) must be completed for the partnership. Include a copy of your partnership agreement. IV. Will this business be operated as a corporation? If “yes”, list the total amount of stock, common and preferred, and each officer, director, and majority stockholder below. Include a copy of the corporate charter and attach a list of all stockholders, amount of stock owned, and their addresses to this application. NAME CORP TITLE ADDRESS SHARES OWNED ________________ ____________ ________________ ________________ ______________________ NOTE: Each officer*, director, and the majority stockholder must submit a PERSONAL RECORD (Form 1001), a SUMMARY FINANCIAL STATEMENT (Form 2007), and two (2) properly executed fingerprint cards with a certified check in the amount of $27.00 made payable to ABC-FF with this application. A separate SUMMARY FINANCIAL STATEMENT (Form 2007) must be completed for the corporation. *Officers owning less than 5% of stock of the corporation do not file a Summary Financial Statement. V. Will this permit be operated as a trust? beneficiary below. NAME TYPE If “yes”, list the trustee and each STATE OF RESIDENCY Note: The trustee and each beneficiary must submit a PERSONAL RECORD (Form 1001), two (2) properly executed fingerprint cards with a certified check for $27.00 made payable to ABCFF with this application. (a SUMMARY FINANCIAL STATEMENT is not required) 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 thereby. I certify that the information presented on this application to be true and correct, to the best of my knowledge and belief. (signature of sole owner, partner, President of Corp, or trustee) DATE NOTARY SWORN TO AND SUBSCRIBED before me, this the day of , NOTARY PUBLIC My commission expires: American LegalNet, Inc. www.FormsWorkflow.com (REVISED 7/01) PERSONAL RECORD ALCOHOLIC BEVERAGE CONTROL PERMIT DEPARTMENT P O BOX 540, MADISON, MS 39130-0540 1. Name (last)  sole owner (first)  partner  officer  stockholder (middle)  director 2. Name of business 3. Date of Birth Social Security Number Driver’s License No. Age Sex Weight Hair Color Eye Color  manager Height Race 4. Telephone No. (home) 5. List your residences for the past five years, starting with current address FROM MO/YR 6. ADRESS CITY,STATE,ZIP CODE List your employment or occupational history for the past five (5) years. FROM MO/YR 7. TO MO/YR (business) TO MO/YR EMPLOYER CITY, STATE Have you filed and paid your Mississippi State Income Taxes and your Federal Income Taxes? If “no”, explain fully: 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 and 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 in any state or local jurisdiction? d. A violation of any drug related Law? --------------------------------------------------------------------------------------------------------------------PERSONAL RECORD SUPPLEMENTAL (if “yes” to a, b, c, or d, above explain fully) List convictions (specific charges) Date and jurisdiction of same --------------------------------------------------------------------------------------------------------------------- APPLICANTS 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: 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 of 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 damage which may result from furnishing the information requested. APPLICANT’S SIGNATURE DATE WITNESSES’ SIGNATURES American LegalNet, Inc. www.FormsWorkflow.com (ABCD 2007) (06/01) SUMMARY FINANCIAL STATEMENT ALCOHOLIC BEVERAGE CONTROL PERMIT DEPARTMENT P O BOX 540, MADISON, MS 39130-0540 I. Name (last) (first) (middle/maiden) II. Name of business III. Financial statement is:  Personal IV. List checking, savings, and/or loan institution references. Continue on separate page if needed.  partnership  corporation  Trust Checking: (institution name) (account number) (institution name) (account number) (institution name) (account number) Savings: Loan: V. List each asset, tangible or intangible, below. These amounts are accurate as of ____________________, _____. Current Assets Cash on hand………………………………………. Cash on deposit……………………………………. Accounts & Notes Receivable……………………. $ $ $ Investments Stocks and Bonds…………………………………. Business Investment………………………………. $ $ Fixed Assets Real estate…………………………………………. Other………………………………………………… $ $ Total Assets………… $ American LegalNet, Inc. www.FormsWorkflow.com VI. List each liability below. These amounts are accurate as of (insert date) , . Current Liabilities (debts due within one year) Accounts Payable (ex. credit cards)………………….. Taxes Payable………………………………………….. Other……………………………………………………… $ $ $ Long Term Liabilities (debts due in more than one year) Notes Payable…………………………………………. Mortgages Payable……………………………………. Other……………………………………………………. $ $ $ Total Liabilities…….. $ WAIVER AND AUTHORIZATION TO RELEASE FINANCIAL INFORMATION TO WHOM IT MY CONCERN: I hereby request and authorize you to furnish the Alcoholic Beverage Control Division, State Tax Commission, with any and all information you may have concerning me or my financial records and copy such records, whether or not such documents would otherwise be protected from disclosure by any constitutional, statutory, or common law privilege. I agree to indemnify and hold harmless the person or organization to whom this request is presented from all manner of actions arising out of or be reason of complying with this request. A reproduction of this request by Xerox or similar process shall be for all intents and purposes as valid as the original. This request shall expire twelve (12) months from date of signing. APPLICANT’S SIGNATURE DATE WITNESSES’ SIGNATURE American LegalNet, Inc. www.FormsWorkflow.com REVISED, 06/01) BOND NUMBER STATE OF MISSISSIPPI SURETY BOND KNOW ALL MEN BY THESE PRESENTS: That we, , of the City of County of State of , as Principal, and , a corporation incorporated under the laws of the State of , and duly licensed to do business in the State of Mississippi, as Surety are held and firmly bound unto the State of Mississippi, obligee, in the sum of dollars ($ ), for the payment of which we bind ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally, firmly by these presents, and Whereas, the Principal has been licensed by the Alcoholic Beverage Control of the State Tax Commission to be a retailer of alcoholic beverages under and by virtue of the provisions of the Local Option Alcoholic Beverage Control Laws of the State of Mississippi at County of day of Street in the City of ,State of Mississippi, for a term beginning the , . The conditions of this obligation are such that if the Principal shall faithfully observe the provisions of the Local Option Alcoholic Beverage Control Laws, Sections 67-1-1, et seq., MCA 1972, as well as Sections 27-71-1 through 27-71-31, MCA 1972, all amendments thereto and Rules and Regulations issued thereunder, and shall pay all taxes, damages, interest, and penalties, which may accrue to the State of Mississippi, including but not limited to sales, income and privilege taxes; and in addition, shall pay any and all checks returned for non-payment to the Alcoholic Beverage Control Division of the Tax Commission, then this obligation shall be void, otherwise to remain in full force and effect, until a release from further liabilities imposed herein is granted in writing; PROVIDED, HOWEVER, that if the Surety shall so elect, this bond may be canceled at any time by the Surety giving sixty (60) days notice in writing addressed to and receipted therefor by the Director of the Alcoholic Beverage Control Division of the State Tax Commission, and upon the giving of such notice, this bond shall be deemed cancelled at the expiration of sixty (6) days therefrom. WITNESS our hand and seal, this the day of , Principal (SEAL) BY: COUNTERSIGNED: Surety BY: Resident Mississippi Agent (if signed by Attorney in Fact, attach copy of written authority Address American LegalNet, Inc. www.FormsWorkflow.com LEGAL NOTICE FORMAT FOR PUBLICATION OF TRANSFER APPLICATION CHECK APPLICABLE PHRASES ( ) I, (sole owner’s name) ( ) We, (partnership name) ( ) We, the officers of ( corporation name) intend to make application for a transfer of: ( ( ( ( ( ( ( ( ( ( ( ( ( ) ) ) ) ) ) ) ) ) ) ) ) ) a Manufacturer Class I, Distiller &/or Rectifier permit a Manufacturer Class II, Wine permit a Manufacturer Class III, Native Wine permit a Package Retailer permit an On-Premises retailer permit an On-Premises retailer, Club permit an On-Premises retailer, Wine only, permit a Common Carrier permit a Native Wine retailer permit a Caterer’s permit, for on-premises retailer permit holders a Caterer’s permit a Solicitor’s permit a Research permit Under the provisions of the Local Option Alcoholic Beverage Control Laws, 67-11 et. seq., Mississippi Code of 1972. If granted a transfer from (name of sole owner, partnership, corporation or trust) doing business as who is operating at (street) (city) , propose to operate under the tradename of (I) (We) at (street number) (street) of County. The name(s), title(s), and address(es) of all owners/ partners/ officer(s) Major stockholder(s) of the above are as follows: This the day of and/or , American LegalNet, Inc. www.FormsWorkflow.com SPECIAL NOTICE The Commission Meetings are normally held each Wednesday at 10:00 a.m.. You will not be notified of the date your application will be considered. Your permit will be mailed immediately after approval. If you elect to pick up your permit at the Liquor Distribution Center office, call Permit Department at 601-856-1330 to make prior arrangements. Your may not place your initial order for alcoholic beverages with the ABC until the day after your permit has been approved by the Commission. We must create your account and establish a delivery route for your business before your order may be processed All new permittees must serve a probationary period. You must pay for your alcoholic beverages with certified funds for a period of no less than ninety (90) days. After this initial period, you may pay for your alcoholic beverages by either a personal/business check or you may elect for ABC to draft your account. If you choose the bank draft system, please contact ABC Accounting at 601-856-1310 for further information. APPLICATION CHECK LIST Have you  included the correct fee payment for the permit?  completed the supplemental information?  compiled a summary financial statement for the business?  Included a copy of your floor planned area?  Included a copy of your lease or deed?  Included a personal record form statement, summary financial statement, two fingerprint cards, and executed a release of information for each person identified on the Statement of Ownership?  Included fee payable to the ABC FF Fund for fingerprint cards?  Included Proof of Publication of your legal notice?  Signed the application where noted and had the signatures notarized and witnessed?  Included the application for transfer? American LegalNet, Inc. www.FormsWorkflow.com ABC TELEPHONE NUMBERS Remove and retain for your records ADMINISTRATION ACCOUNTING ENFORCEMENT PERMIT PROCESSING PURCHASING (SPECIAL ORDERS) WAREHOUSE 856-1301 856-1310 856-1320 856-1330 856-1360 856-1340 856-1380 TO PLACE AN ORDER FOR ALCOHOLIC BEVERAGES CALL 856-1350 American LegalNet, Inc. www.FormsWorkflow.com