TRANSFER APPLICATION OFFICERS OF AN ON-PREMISES RETAILER CLUB 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 officers of your club 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. First, complete SECTION I - STATEMENT OF OWNERSHIP. This form will show all of the officers of your establishment. Next, complete the PERSONAL RECORD (Form 1001) for each new officer. Attach to these forms two (2) properly executed fingerprint cards for each personal record form submitted. ABC collects a pass-along fee for fingerprint card processing by the Federal Bureau of Investigation. This fee is due and payable with the application submission. This fee is $27.00 per person. Make your money order or cashier’s check payable to ABC FF. YOUR MISSISSIPPI STATE INCOME TAX FILING STATUS WILL BE VERIFIED FOR THE PAST THREE (3) YEARS. THIS OFFICE ALSO REPORTS TO THE INTERNAL REVENUE SERVICE THAT YOU HAVE APPLIED FOR A PERMIT. IF YOU HAVE FAILED TO FILE YOUR FEDERAL OR STATE RETURNS WHEN DUE, YOU MAY CONTACT THE IRS AND/OR STATE TAX COMMISSION OFFICE IN YOUR AREA FOR ASSISTANCE. WHEN YOU HAVE FILED ALL LATE RETURNS AND PAID ANY TAXES DUE, PLEASE REQUEST THE STATE TAX COMMISSION TO CONTACT OUR OFFICE TO VERIFY THAT YOUR FILING STATUS IS CURRENT. WE MUST HAVE THIS VERFICATION IN ORDER TO CONTINUE PROCESSING YOUR APPLICATION. Last, review your application to be sure that you have completed it properly. Send your application forms to: ALCOHOLIC BEVERAGE CONTROL PERMIT DEPARTMENT P.O. BOX 540 MADISON, MS. 39130-0540 IF YOUR NEED ASSISTANCE, CALL ABC PERMIT DEPT. (601) 856-1330. American LegalNet, Inc. www.FormsWorkflow.com SECTION I -- STATEMENT OF OWNERSHIP ALCOHOLIC BEVERAGE RETAILER PERMIT APPLICATION. I. Name of business__________________________Permit No.__________ II. Will this business be operated as an on premises retailer club as defined by S. 67-1-5(n) of the 1972 MCA?_________ If "yes", list the officers and directors of the club below. NAME TITLE _____________________________ ________________________________ _____________________________ ________________________________ _____________________________ ________________________________ _____________________________ ________________________________ _____________________________ ________________________________ NOTE: Each person listed above must submit a PERSONAL RECORD (Form 1001) and two (2) FINGERPRINT CARDS with a certified check or money order for $27.00 made payable to ABC-FF with this application. PERMITTEE CERTIFICATION AND OATH 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 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 ________________________________ TITLE SWORN TO AND SUBSCRIBED before me, this the______day of___________19___. ________________________________ notary public My commission expires:_________________________ Form 1001 (11/95) American LegalNet, Inc. www.FormsWorkflow.com 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: ________________________________ American LegalNet, Inc. www.FormsWorkflow.com SPECIAL NOTICE Upon approval by the ABC, your permit file will be updated and all correspondence mailed to the new officers. You will not be notified prior to these changes. APPLICATION CHECK LIST Have you _ included a (PERSONAL RECORD) for each new officer, and two properly executed fingerprint cards? _ included fee made payable to the ABC FF Fund for fingerprint cards? _ signed the application where noted and had the signatures notarized? American LegalNet, Inc. www.FormsWorkflow.com