MISSOURI DEPARTMENT OF PUBLIC SAFETY DIVISION OF ALCOHOL AND TOBACCO CONTROL APPLICATION BY SOLE OWNER AND OPERATOR 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 I, the undersigned, hereby apply to the Supervisor of Alcohol and Tobacco Control of the State of Missouri for the license and upon the premises described herein, and for the purposes of inducing the Supervisor to issue me said license, I make the statements and answers hereinafter set out. I am, and will continue to be throughout the term for which this license is sought, the Sole Owner and Operator of the business for which this license is sought. 1. FULL NAME AS SOLE OWNER AND OPERATOR (last, first, middle) RESIDENCE: TELEPHONE NO: HOME BUSINESS SSN: PLACE OF BIRTH: DATE OF BIRTH: 2. List all addresses for preceding ten years (begin with current address) 3. If you are a naturalized citizen, give the date and court in which you were admitted to citizenship. 4. 5. 6. In what city, town or village do you pay taxes? Where are you registered to vote? PRECINCT: CITY: WARD: COUNTY: Do you or any member of your household or immediate family 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. Have you, or any member of your household or immediate family, 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. Have you or any member of your household or immediate family 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: DATE: COURT: 9. Have you or any member of your household or immediate family 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 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 imposition of sentence for, or been convicted of any crime? If so, give details: 11. Have you ever been employed by any person, partnership, corporation or other entity that 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. Have you, or any person with a direct or indirect interest in the business, 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 law of 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 corporation or other entity for which you have 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, law of the State of Missouri or law of any other state or country? If so, give details: 14. Have you or any person with a direct or indirect interest in the business ever been charged with or indicted for, received 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: 15. Have you or any person with a direct or indirect interest in the business ever been charged with or indicted for, received 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: 16. Specify if you own, rent or lease the premises: Enter landlord’s name and address: MO 812-0150N (1-05) State terms of agreement: American LegalNet, Inc. www.FormsWorkflow.com 17. What interest, if any, does the landlord or previous owner have, directly or indirectly, in the business in which you intend to engage, or in the real property on which it is located? 18. If you purchased the business: (A) Give the name of the former owner from whom you purchased it (B) The amount you paid for it , and (C) State in detail the terms and manner of payment. 19. Give the names of any person, firm, corporation, or other entity holding any mortgage or encumbrance of any kind against the business for which you seek 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 you to purchase or operate the business for which you seek a license. Give details: 21. Do you 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 in which you seek a license: 23. State the name of any distiller, wholesaler, 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 you except ordinary commercial credit for intoxicating liquor and/or non-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, except those you listed in question 23,who has or will have directly or indirectly a financial investment or interest in the business for which you seek a license, and state the nature of such investment or interest. (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 premises 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 yourself 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! I understand that false answers made herein may result in the Supervisor’s denial of this license application. I understand that 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. I 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 my license t o suspension, revocation, fine, probation, or other discipline by the Supervisor. Further, I agree to allow inspections made in accordance with the Rules and Regulations of the Supervisor of Alcohol and Tobacco Control, and I 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 way to this business, including, but not limited to, those on file with any bookkeeper or other agent. I authorize 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 my financial institution(s), and any financial documents related to the business. The undersigned authorizes the Supervisor of Alcohol and Tobacco Control or his duly appointed agents to conduct a criminal record check of the undersigned. (TYPE OR PRINT NAME) I, , of lawful age, being first duly sworn upon my oath, depose and say that I 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. DATE SOLE OWNER AND OPERATOR SIGNATURE 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 812-0150N (1-05) DISTRICT SUPERVISOR American LegalNet, Inc. www.FormsWorkflow.com