MISSOURI DEPARTMENT OF PUBLIC SAFETY DIVISION OF ALCOHOL AND TOBACCO CONTROL REQUIRED TO BE SUBMITTED ON LEGAL SIZE PAPER APPLICATION BY CORPORATION FOR RETAIL LICENSE DIVISION USE ONLY - DO NOT WRITE IN THIS SPACE STAMP LICENSE TYPE HERE DATE ISSUED DATE EXPIRES EXISTING LICENSE NUMBER LICENSE NUMBER LICENSEE’S NAME FEE ENCLOSED DOING BUSINESS AS TELEPHONE NUMBER ADDRESS COUNTY CITY ADMINISTRATIVE CODES LEGAL DESCRIPTION MAILING ADDRESS SUPERVISOR OF ALCOHOL AND TOBACCO CONTROL ZIP CODE USE ONLY BLACK INK TO COMPLETE THIS APPLICATION - PLEASE TYPE OR PRINT THE FOLLOWING INFORMATION The undersigned corporation hereby applies to the Supervisor of Alcohol and Tobacco Control of the State of Missouri for a lice nse for the premises described herein, and for the purpose of inducing the Supervisor to issue it said license, makes the statements and answers hereinafter set out. 1. Please give the following information for the managing officer of the corporation for which the license is sought. FULL NAME: SSN: PLACE OF BIRTH: HOME PHONE: ( DATE OF BIRTH: ) BUSINESS PHONE: 2. List all addresses of managing officer for preceding ten years (begin with current address). 3. If managing officer is a naturalized citizen, give information concerning admission to citizenship. DATE: COURT: 4. City, town or village where managing officer pays taxes: 5. Managing officer registered to vote in: PRECINCT: 6. Legal name of corporation: Date of incorporation: CITY: Place: WARD: COUNTY: Missouri Secretary of State Corporation File No.: Mailing address: Location of corporation principal office: 7. State the following for each officer of the corporation (Attach additional sheet(s) if necessary): OFFICE HELD NAME RESIDENCE PHONE NO. DATE OF BIRTH NO. OF SHARES HELD SSN PRESIDENT VICE PRESIDENT SECRETARY TREASURER State the following for each shareholder of the corporation (Attach additional sheet(s) if necessary): SHAREHOLDER NAME RESIDENCE PHONE # DATE OF BIRTH NO. OF SHARES HELD SSN 8. Do any of the following hold a direct or indirect interest in any other license issued by the Supervisor of Alcohol and Tobac co Control which is now in force: the corporation itself, the managing officer, any officer or director, any shareholder or person with an interest in a shareholder, or any member of the households or immediate familes of the preceding? If so, give details: 9. Has any party listed in Question 8 ever held a license from the Supervisor of Alcohol and Tobacco Control or ever had a finan cial interest in any entity which held such a license? If so, give name of such licensee and location of premises: 10.Has any party listed in Question 8 ever made application for a license which was denied by the Supervisor of Alcohol and Tob acco Control, or by the licensing authority of any other state, county or city? If so, give details: 11.Have any of the parties listed in Question 8 ever held a license or had a financial interest in a license which was suspende d, revoked, fined, placed on probation or otherwise disciplined by the Supervisor of Alcohol and Tobacco Control, or by the licensing authority of any ot her state, county or city? If so, give details: 12.Is there now employed, or will the corporation employ, in the business sought to be licensed, any person who has at any time held or had an interest in a license, or in an applied-for license, from the Supervisor of Alcohol and Tobacco Control which was suspended, revoked, fined, placed on probation or otherwise disciplined, or which was denied, or any person who has been charged with or indicted for, received a suspended im position of sentence for, or been convicted of any crime? If so, give details: 13.Has any officer, director, managing officer, shareholder or person with an interest in a shareholder, ever been employed by any entity that has had a license revoked, suspended, fined, placed on probation or otherwise disciplined by the Supervisor of Alcohol and Tobacco Contro l of the State of Missouri? If so, give details: 14.Has the corporation itself, the managing officer, any shareholder, any officer, any director, or any other person with a direct or indirect financial interest in the corporation ever been charged with or indicted for, received a suspended imposition of sentence for, or been convicted of a violation of any Federal law, law of the State of Missouri or any other state or country, or entered and/or been present in the United States in violation of Federal immigration laws? If so, give details: MO 812-0868N (1-05) American LegalNet, Inc. www.FormsWorkflow.com 15. Have any of the parties listed in Question 14 ever been convicted of the violation of any city ordinance relating to intoxicating liquor, non-intoxicating beer, gambling, immorality, fighting, peace disturbance or narcotics? If so, give details: 16. Have any of the parties listed in Question 14 ever been charged with, indicted for, received a suspended imposition of sentence for, or been convicted of the violation of any Federal law, law of the State of Missouri or any other state or country, of any Federal law or law of any state concerning intoxicating liquor or non-intoxicating beer? If so, give details: 17. Has any corporation or other entity of which any party listed in Question 14 has been managing officer, shareholder, director, officer or member ever been charged with or indicted for, received a suspended imposition of sentence for, or been convicted of a violation of any Federal law, law of the State of Missouri or of any other state or country? If so, give details: 18. Specify if the corporation owns, rents or leases the premises STATE TERMS OF AGREEMENT: ENTER LANDLORD’S NAME AND ADDRESS: 19. What interest, if any, does the landlord or previous owner have, directly or indirectly, in the business in which the corpor ation intends to engage, or in the real property on which it is located? 20. If the corporation purchased the business: (A) Give name of former owner from whom it was purchased (B) State the amount paid for the business , and (C) State in detail the terms and manner of payment 21. State the name and address of any person, firm, corporation or other entity holding any mortgage or encumbrance of any kind against the business for which this license is sought, and state amount of mortgage or encumbrance and terms of payment. (If none, so state.) 22. State name of any person, firm, corporation or other entity that has advanced, loaned or otherwise made available, or that will do so, any money for the corporation to purchase or operate the business for which this license is sought. Give details: 23. Does the corporation or any officer, director, shareholder or the managing officer have any direct or indirect financial interest in any brewery, winery, distillery, rectifying or blending plant, or gasohol facility, or wholesale liquor or beer concern, either as part owner, share holder, agent, employee or otherwise? If so, give details: 24. State the name and address of any distiller, wholesaler, winemaker, or brewer, or any employee, officer or agent thereof, who will, directly or indirectly, loan, give away, or furnish equipment, money, credit, or property of any kind to the corporation, except ordinary commercial credit for liquor and/or nonintoxicating beer sold to the corporation and except such articles and services, if any, as are permitted by the regulations of the Supervisor of Alcohol and Tobacco Control, or of any who has done so. (If none, so state): 25. State the name and address of any person, firm, corporation or other entity, other than shareholders, who has or will have a direct or indirect financial investment or interest in the business for which the corporation seeks a license, and state the nature of such interest. (If non e, so state:) 26. What is the distance in feet, measured in a straight line, from the nearest point of the above described premises to the nearest point of the nearest school, church, or other building regularly used as a place of religious worship? 27. Do you understand that the herein named managing officer must be a person in the applicant’s employ, either as officer or an employee who is vested with the general control and superintendence of a whole, or a particular part of, the corporation’s business at a particular place? Do you meet this requirement? 28. If a license is granted, does the corporation agree that it will first obtain the approval of the Supervisor of Alcohol and Tobacco Control of the State of Missouri before naming any other person as managing officer, other than the person named herein, who should be actively in char ge of the business during the term for which the license is granted? 29. In what bank(s) or other financial institution(s) does/will the applicant maintain the financial accounts for the business seeking license herein? (Include both name and address.) 30. Is this application being made by the corporation as a subterfuge to permit any person or entity other than the corporation to secure a license from the Supervisor of Alcohol and Tobacco Control, in your name, for his/its benefit? IMPORTANT You are required to report any change of fact contained herein within ten(10) days! The corporation understands that false answers are grounds for denial of a license. The corporation understands that if any statements or answers made herein are untrue and the license herein applied for is gran ted, such license may be revoked, suspended, fined, placed on probation or otherwise disciplined by the Supervisor. The corporation acknowledges that any license granted by the Supervisor will be subject to the provisions of Chapters 311 and 3 12, RSMo, and the Rules and Regulations of the Supervisor of Alcohol and Tobacco Control, and that failure to conform thereto will subject its license to suspension, revocation, fine, probation or other discipline by the Supervisor. Further, the corporation agrees to allow inspections made in accordance with the Rules and Regulations of the Supervisor of Alcohol and Tobacco Control, and authorizes the Supervisor of Alcohol and Tobacco Control or his duly appointed agents to examine and secure copies of any and all business records or documents related in any way to this business, including, but not limited to, those on file with any bookkeeper. The corporation authorizes the Supervisor of Alcohol and Tobacco Control or his duly appointed agents to examine and secure copies of any and all financial records, including without limitation, signature cards, checking and savings account statements, notes and loan documents, deposit and withdrawal records, and escrow documents of its financial institution(s), and any financial documents related to the business. The corporation authorizes the Supervisor of Alcohol and Tobacco Control or his duly appointed agents to conduct a criminal record check of the managing officer and of all of the corporation’s officers, directors, and stockholders owning ten percent or more of the stock of such corporation. MO 812-0868N (1-05) American LegalNet, Inc. www.FormsWorkflow.com I, , of lawful age, being first duly sworn upon my oath, depose and say that I (TYPE OR PRINT NAME) have read this application and fully understand same and that I know the contents thereof and the answers and statements contained therein and that the same are true. SIGNATURE OF MANAGING OFFICER EXACT NAME OF CORPORATION (TYPE OR PRINT) NOTARY INFORMATION NOTARY PUBLIC EMBOSSER OR BLACK INK RUBBER STAMP SEAL STATE OF COUNTY (OR CITY OF ST. LOUIS) SUBSCRIBED AND SWORN BEFORE ME, THIS DAY OF NOTARY PUBLIC SIGNATURE YEAR USE RUBBER STAMP IN CLEAR AREA BELOW. MY COMMISSION EXPIRES NOTARY PUBLIC NAME (TYPED OR PRINTED) FOR OFFICE USE ONLY Based on the information contained herein, the undersigned forward this application for consideration by the Supervisor of Alcohol and Tobacco Control and hereby recommend that this application be approved and the license issued. AGENT MO 812-0868N (1-05) DISTRICT SUPERVISOR American LegalNet, Inc. www.FormsWorkflow.com