TRANSFER APPLICATION CORPORATE NAME 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 a transfer in the corporate name of your 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. The application immediately follows these instructions. The permit transfer fee is a non-refundable $25.00. If you are currently on certified funds, then you will need to submit a cashier’s check or money order. If you are not on certified funds then you may submit a personal check or company check. Complete the APPLICATION FOR TRANSFER. This form is essential for processing your transfer application correctly. Make sure that you complete this form accurately. Include the following additional information: A) You will need to obtain a "RIDER" from your insurance company changing the corporate name on your bond. If you have a cash bond, you will need to complete new forms. If you have a Certificate of Deposit, then you will need a letter from your bank stating that they have changed their records to reflect the new name. B) Include a copy of the approved amendment to your corporate charter by the Secretary of State. Last, review your application to be sure that you have completed it properly. Send your application forms 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 ABC Permit Department at (601) 856-1330. American LegalNet, Inc. www.FormsWorkflow.com (REVISED) 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) _____________________________________________________, hereby (city) (county) submit application for a transfer in corporate name to: ______________________________________ 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:___________________________ V. List the total amount of stock,________common and ________preferred, and each officer, director, and majority stockholder below. Include a copy of the amended charter and attach a list of stockholder, amount of stock owned, and their addresses to this application. NAME CORP. TITLE ADDRESS AMT. SHARES ___________________ _______________ ______________ ___________________ _______________ ___________________ _______________ __________________ __________________ __________________ __________________ __________________ __________________ ______________ ______________ American LegalNet, Inc. www.FormsWorkflow.com ___________________ _______________ __________________ __________________ ______________ American LegalNet, Inc. www.FormsWorkflow.com 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 67-1-69, of the Mississippi Code 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 ___________________ SIGNATURE ____________________________ TITLE SWORN TO AND SUBSCRIBED before me, this the ______day of ________________.19_____. ____________________________ NOTARY PUBLIC My commission expires:_____________________________ 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, please call 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 for transfer? _ included a "rider" changing the corporate name on your bond? _ included a copy of the amendment to your corporate charter? _ completed the permittee certification? American LegalNet, Inc. www.FormsWorkflow.com