MONTANA Form M-1 Rev 02 11 Secured Party Addition Please be sure to include names and signatures of all participants. Name of Borrower/Debtor _________________________________________________________________________________________________ Address _________________________________________________________________________________________________ Street City State Zip Name of Lender/Secured Party _________________________________________________________________________________________________ Address _________________________________________________________________________________________________ Street City State Zip License No. - - - Doing Business As______________________________________ Loan No._________________________ Location Address __________________________________________________ Affirmation and Signatures The undersigned hereby request that the person(s) named above be endorsed on the face of the license as a secured party. Dated this ___________day of ________________, 20________ Signature of Borrower/Debtor Signature of Lender/Secured Party ______________________________________________ ________________________________________________ Signature Date Signature Title Date ______________________________________________ Printed Name ________________________________________________ Printed Name ______________________________________________ ________________________________________________ Signature Date Signature Title Date ______________________________________________ Printed Name ________________________________________________ Printed Name Return to: Montana Department of Revenue Liquor Licensing PO Box 1712 Helena, MT 59624-1712 *11MW0101* *11MW0101* American LegalNet, Inc. www.FormsWorkFlow.com