MISSOURI DEPARTMENT OF PUBLIC SAFETY DIVISION OF ALCOHOL AND TOBACCO CONTROL APPLICATION BY PARTNERSHIP FOR RETAIL LICENSE DIVISION USE ONLY - DO NOT WRITE IN THIS SPACE 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 hereby apply to the Supervisor of Alcohol and Tobacco Control of the State of Missouri for a license for the premises described herein, and for the purpose of inducing the Supervisor to issue them said license, make the statements and answers hereinafter set out. We hereby state and affirm that we are, and will continue to be throughout the term of this license, the owners and operators as a Partnership of the business for which this license is sought. 1. State the following for each partner in the partnership known as Bus. Phone (Attach additional sheets if necessary) NAME RESIDENCE PLACE OF BIRTH DATE OF BIRTH % OWNED TELEPHONE SSN A. B. C. D. 2. List all addresses for preceding ten years (beginning with current address) for each partner A. B. C. D. 3. State the name of the city, town, or village where each partner pays taxes. (A) (B) (C) (D) 4. State the precinct, city, ward, and/or county where each partner is registered to vote. (A) (B) (C) (D) 5. If any partner is a naturalized citizen, give the partner’s name and the court and date in which he/she was admitted to citizenship. Name Court Date 6. Does any partner or member of his immediate family or household hold a direct or indirect interest in any other license issued by the Supervisor of Alcohol and Tobacco Control which is now in force? If so, list each licensee name and location of premises: 7. Has any partner or any member of his immediate family or household ever held a license from the Supervisor of Alcohol and Tobacco Control or ever had a financial interest in any entity which held such a license? If so, list each licensee name and location of premises: 8. Has any partner or any member of his immediate family or household ever made application for a license which was denied by the Supervisor of Alcohol and Tobacco Control or by the licensing authority of any other state, county, or city? If so, give details: 9. Has any partner or any member of his immediate family or household ever held a license or had a financial interest in a license which was suspended, revoked, fined, placed on probation or otherwise disciplined by the Supervisor of Alcohol and Tobacco Control, or by the licensing authority of any other state, county, or city? If so, give details: 10. Is there now employed or will you employ in the business sought to be licensed any person who has at any time held 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 imposition of sentence for, or been convicted of any crime? If so, give details: 11. Has any partner ever been employed by any person, partnership, corporation or other entity that has had a license suspended, revoked, fined, placed on probation or otherwise disciplined by the Supervisor of Alcohol and Tobacco Control? If so, give details: 12. Has any partner or any person with a direct or indirect financial interest in the business 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: 13. Has any partner or any person with a direct or indirect interest in the business ever been charged with or indicted for, rec eived a suspended imposition of sentence for, or 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: 14. Has any partner or any person with a direct or indirect interest in the business ever been charged with or indicted for, rec eived a suspended imposition of sentence for, or been convicted of any Federal law, or law of any state concerning intoxicating liquor or non-intoxicating beer? If so, give details: 15. Has any corporation or other entity of which any partner has been managing officer, shareholder, officer, director 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 or law of any other state or country? If so, give details: MO 812-0149N (12-04) American LegalNet, Inc. www.FormsWorkflow.com 16. Specify if you own, rent, or lease the premises: State terms of agreement: Enter landlord’s name and address: 17. What interest, if any, does the landlord or previous owner have, directly or indirectly, in the business in which the partnership intends to engage, or in the real property on which it is located? 18. If the partnership 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 19. 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 the partnership seeks a license, and state amount of mortgage or encumbrance and terms of payment (if none, so state). 20. State name of any person, firm, corporation or other entity that has advanced, loaned or otherwise made available, or that w ill do so, any money for the partnership to purchase or operate the business for which the partnership seeks a license (if none, so state). 21. Does the partnership or any partner have any interest directly or indirectly in any brewery, winery, distillery, rectifying or blending plant, or gasohol facility, or wholesale liquor or beer concern, either as part owner, stockholder, agent, employee or otherwise? If so, give details 22. State the name and address of any distiller, wholesaler, winemaker, or brewer, or any employee, officer or agent thereof, who has, or who will have, any financial interest, directly or indirectly, in the business: 23. State the name 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, except ordinary commercial credit for liquor and/or no n-intoxicating beer sold to you, 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). 24. State the name and address of any person, firm, corporation or other entity, who has or will have a direct or indirect financial investment or interest in the business for which the partnership seeks a license, and state the nature of such interest; except those already listed in your response to Question 23 (if none, so state). 25. 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? 26. 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.) 27. Is this application being made by you as a subterfuge to permit any person or entity other than the partnership 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! We understand that false answers made herein may result in the Supervisor’s denial of this license application. We understand th at if any statements or answers made herein are untrue and the license herein applied for is granted, such license may be revoked, suspended, fined, placed on probation or otherwise disciplined by the Supervisor. We understand that any license granted by the Supervisor will be subject to the provisions of Chapters 311 and 312, RSMo, and the Rules and Regulations of the Supervisor of Alcohol and Tobacco Control, and that failure to conform thereto will subject our license to suspension, revocation, fine, probation or other discipline by the Supervisor. Further, we agree to allow inspections made in accordance with the Rules and Regulations of the Supervisor of Alcohol and Tobacco Control, and we authorize 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 w ay to this business, including, but not limited to, those on file with any bookkeeper. We authorize the Supervisor of Alcohol and Tobacco Control or his duly appointed agents to examine and secure copies of financi al records, including, without limitation, signature cards, checking and savings account statements, notes and loan documents, deposit and withdrawal records, and escrow documents of our financial institution(s), and any financial documents related to the business. The undersigned partners authorize the Supervisor of Alcohol and Tobacco Control or his duly appointed agents to conduct a criminal record check of all partners. We, , , (TYPE OR PRINT NAME) (TYPE OR PRINT NAME) , , (TYPE OR PRINT NAME) (TYPE OR PRINT NAME) of lawful age, being first duly sworn upon our oaths, depose and say that we have read this application and fully understand same and that we know the contents thereof and the answers and statements contained therein and that the same are true. PARTNER SIGNATURE PARTNER SIGNATURE PARTNER SIGNATURE PARTNER SIGNATURE NOTARY PUBLIC NOTARY PUBLIC EMBOSSER OR BLACK INK RUBBER STAMP SEAL STATE 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 812-0149N (12-04) DISTRICT SUPERVISOR American LegalNet, Inc. www.FormsWorkflow.com