TRANSFER APPLICATION CORPORATE STRUCTURE ALCOHOLIC BEVERAGE PERMIT 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 for a transfer in your corporate officers. 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, 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. This application may be typed or neatly printed in ink. The application immediately follows these instructions. The permit fee included is a non-refundable $25.00 processing fee. Next, complete the APPLICATION FOR TRANSFER. This form needs to be completed in its entirety. Then, complete the STATEMENT OF OWNERSHIP. This form contains instructions on who must file qualifying documents (PERSONAL RECORD Form 1001; SUMMARY FINANCIAL STATEMENT, Form 2007; and two (2) properly executed fingerprint cards) with this application. Note that the officers and corporation must file separate SUMMARY FINANCIAL STATEMENTS. Also include a copy of the corporate minutes listing this change . If stock were sold, you also will need to submit a copy of the stocks sold. ABC collects a pass - along fee for the fingerprint card processing by the Federal Bureau of Investigation. This fee is due and payable with the application submission. The fee collected is a $27.00 fee for each applicant and made payable to ABC FF. This must be in the form of certified funds. Signatures on each PERSONAL RECORD form must be notarized and the waiver portion of the SUMMARY FINANCIAL STATEMENT form must be completed. Four (4) PERSONAL RECORD forms and five (5) SUMMARY FINANCIAL STATEMENT forms as well as the appropriate amount of fingerprint cards are included in this application packet. Contact ABC Permit Department if you need additional forms. Be sure to complete the PERMITTEE CERTIFICATION AND OATH along with the WAIVER AND AUTHORIZATION TO RELEASE INFORMATION. This release will assist us in verifying information on your application. American LegalNet, Inc. www.FormsWorkflow.com You may be required to publish notice of your application. If you are an officer who owns 5% or more of stock, or a majority stockholder with 5% or more stock, then you will be required to publish your intent. You are required to publish notice of your application in two (2) consecutive issues of a newspaper published in the town in which the business will be located. If no local newspaper exists, the notice may be published in the newspaper produced in the town 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. Last, review the application check list. Be sure to include proper payment and send the completed forms to: ALCOHOLIC BEVERAGE CONTROL PERMIT DEPARTMENT P.O. BOX 540 MADISON, MS 39130-0540 Please allow ample time for processing your application. If you need assistance, call ABC Permit Department at (601) 856-1330 American LegalNet, Inc. www.FormsWorkflow.com REVISED (5/96) PERMIT DEPT USE ONLY AMT OF CHECK________ CHECK NUMBER_______ PERMIT NUMBER______ APPLICATION FOR TRANSFER IN OFFICERS/STOCK OF ALCOHOLIC BEVERAGE RETAILERS PERMIT I,__________________________________________,hereby submit application (corporate officer’s name president/vice president) for a transfer in officers of: __________________________________________ (corporate name) _____________________________________________________________________________________________. (doing business as) Telephone Number (business)______________________ (home)_________________________________ II. Does the applicant have, or has the applicant ever had, an interest in any other alcoholic beverage retailer’s permit?________ If "yes", explain fully: __________________________________________________________ __________________________________________________________ III. 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:______________ __________________________________________________________ IV. List your Mississippi Sales Tax Number:___________________________ STATEMENT OF OWNERSHIP ALCOHOLIC BEVERAGE RETAILER PERMIT APPLICATION I. List the amount of stock ,__________common and preferred, _________ and each officer, director, and majority stockholder below. Include a copy of the corporate minutes showing this change along with a copy of the stocks sold. 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 for $27.00 made payable to ABC FF with this application. A separate SUMMARY FINANCIAL STATEMENT must be completed for the corporation. American LegalNet, Inc. www.FormsWorkflow.com PERMITTEE CERTIFICATION AND OATH I,_______________________________, certify under penalty of perjury that the organization applying for the 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 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. __________________________ Date:___________________ __________________________ (title) SWORN TO AND SUBSCRIBED before me, this the_____of______________________, ____________. ___________________________________ Notary Public My commission expires:____________________________ American LegalNet, Inc. www.FormsWorkflow.com Form 1001 (11/95) PERSONAL RECORD ALCOHOLIC BEVERAGE CONTROL PERMIT DEPARTMENT P.O. BOX 540, MADISON, MS. 39130-0540 1. Name _____________________________________________________ (last) _ sole owner _ (first) partner _ officer _ (middle) stockholder _ manager 2. Name of business ____________________________________________ 3. Date of Birth ________________ Social Security No. _______________ Driver’s License No. _____________________ Age _______ Sex _____ Height ____________ Weight ____________ Hair color ____________ Eye color __________ Race ___________ 4. Telephone No. (home) ________________ (business) _________________ 5. List your residences for the past five years, starting with current address. FROM MO./YR. TO MO./YR. ADDRESS CITY, STATE, ZIP CODE ________ ________ ________ ________ _____________________________________ ________ ________ _____________________________________ ________ ________ _____________________________________ ________ ________ 6. _____________________________________ _____________________________________ List your employment or occupational history for the past five (5) years. FROM MO./YR. TO MO./YR. EMPLOYER CITY, STATE ________ ________ _____________________________________ ________ ________ _____________________________________ ________ ________ _____________________________________ ________ ________ _____________________________________ ________ ________ _____________________________________ American LegalNet, Inc. www.FormsWorkflow.com 7. Have you filed and paid your Mississippi State Income Taxes and your Federal Income Taxes? _________________ If "no", explain fully: __________________________________________________________ __________________________________________________________ 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 drunk 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: ________________________________ ABCD 2007 (11/95) American LegalNet, Inc. www.FormsWorkflow.com 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 _ partnership _ corporation IV. List checking, savings, and/or loan institution references. Continue on separate page if needed. Checking: ____________________________________________ (institution name) (account number) Savings: _____________________________________________ (institution name) (account number) Loan: ________________________________________________ (institution name) V. (account number) List each asset, tangible or intangible, below. These amounts are accurate as of (insert date) ______________________ , ______ . Current Assets Cash on hand ..................................... $_______________ Cash on Deposit ................................. $_______________ Accounts & Notes Receivable ............. $_______________ Investments Stocks and Bonds .............................. $_______________ Business Investment ........................... $_______________ Fixed Assets Real estate ........................................ Other ................................................. $_______________ $_______________ Total Assets ................... $_______________ VI. List each liability below. These amounts are accurate as of (insert date) ___________________ , _______ . Current Liabilities (debts due within one year) American LegalNet, Inc. www.FormsWorkflow.com 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 MAY 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 to whom this request is presented from all manner of actions arising out of or by 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 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) 8561330 to make prior arrangements. APPLICATION CHECK LIST Have you included the proper permit fee completed the supplemental information compiled a summary financial statement for the business included a personal record 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 included copies of corporate minutes and copies of stock certificates signed the application where noted and had the signatures notarized American LegalNet, Inc. www.FormsWorkflow.com