1 LTD 06 Revision Date NEVADA STATE LIQUOR LICENSE APPLICATION The Board of County Commissioners or Incorporated Cities Governing Body Members must forward the approved and signed Form LTD 06 application to the Nevada Department of Taxation (NRS 369.200). Please note Per NRS 369.220 (3) the Nevada State Liquor License is nontransferable. 1 Application is being submitted for New Business Location Change Additional Location Taxpayer ID: 2 Application is for : Importer/Wholesaler Liquor License Manufacturer Liquor License 3 Importer/Wholesaler License Type (Check all that apply): Importer and Wholesaler of Wine, Beer and Spirits Importer and Wholesaler of Beer Wholesaler of Wine, Beer and Wholesaler of Beer 4 Manufacturer License Type (Check all that apply): Brew Pub Brewer Craft Distillery Estate Distillery Instructional Wine Facility Winemaker Rectifier 5 Business Type: Corporation LLC Partnership Individual Other: 6 Date Incorporated/Organized: State where Incorporated/Organized: 7 Anticipated Start Date of Location: Federal Tax ID: 8 Name of Business:Phone Number: 9 DBA, if any: Fax Number: 10 Business Address: 11 Location of Operation: 12 Mailing Address: 13 Email Address: 14 List All Owners, Officers, Members, Partners, etc. Attach Additional Sheets if Needed. Name: Title: SSN: Residence Address: % Owned: Name: Title: SSN: Residence Address: % Owned: Name: Title: SSN: Residence Address: % Owned: Name: Title: SSN: Residence Address: % Owned: American LegalNet, Inc. www.FormsWorkFlow.com 2 LTD 06 Revision Date 1 15 If Partnership, is the a greement recorded? Yes No In what county and city is it recorded in? 16 Operating under a F ictitious Firm Name? Yes No (Supply a certified copy of the certificate to the Department) In what county and city is it recorded in? 17 Has applicant applied for a local County or City l icense? Yes No If so, where? 18 Has applicant secured all necessary Federal permits? Yes No TTB Permit Number (Supply a copy of permit): 19 Is the location of operations shared with any other business? Yes No If yes, please provide the following: Business Name: Type of Operations: Business Name: Type of Operations: Business Name: Type of Operations: 20 Does any person listed on this application engage in manufacturing, importing, wholesaling or retailing alcoholic beverages through another company? Yes No If yes, please provide the following: Person222s Name: % Owned: Business Name: Type of Operations: Person222s Name: % Owned: Business Name: Type of Operations: 21 Have any individuals with interest, financial or otherwise, in the applicant222s business, ever been convicted of a violation of Federal or any state liquor laws? Yes No If so, provide the following: Name: When: Explain: 22 APPLICANT222S AFFIRMATION: By signing I certify that, to the best of my knowledge under penalty of perjury, the information contained herein is correct and acknowledge that pursuant to Nevada Revised Statutes (NRS) 239.330, it is a category C felony to knowingly offer any false or forged instrument for filing to the Nevada Department of Taxation. In addition, if I am granted a liquor license, I understand that I am expected to comply with all liquor laws, including, but not limited to NRS 369 and 597, Nevada Administration Code, and all Federal laws. Noncompliance can result in fines , suspension or revocation of my license , and criminal prosecution . Name of responsible party: Title: Signature: Date: APPLICATION SUBMITTAL LOCATIONS If the location of business operations is in one of the following cities, Boulder City, Caliente, Carlin, Carson City, Elko, Ely, Fallon, Fernley, Henderson, Las Vegas, Lovelock, Mesquite, North Las Vegas, Reno, Sparks, Wells, West Wendover, Winnemucca or Yerington, then Submit page 1, 2 and 3 to that I ncorporated Cities Governing Board for review. All other locations, submit page 1, 2 and 4 to the Board of County Commissioners for review. American LegalNet, Inc. www.FormsWorkFlow.com 3 LTD 06 Revision Date 17 INCORPORATED CITIES APPROVAL PAGE For Incorporated Cities Only: Boulder City, Caliente, Carlin, Carson City, Elko, Ely, Fallon, Fernley, Henderson, Las Vegas, Lovelock, Mesquite, North Las Vegas, Reno, Sparks, Wells, West Wendover, Winnemucca and Yerington To show validity please attach letter on Incorporated Cities Letterhead attesting to the fact the application was approved or denied, listing the name of the business, the specific liquor license type and the date of approval or denial. Please add any remarks and recommendations by the Incorporated Cities Governing Body Members. FOR OFFICIAL USE ONLY In order to be valid, we require signature(s) by the Incorporated Cities Governing Body Member(s): Title: Signature: Title: Signature: Title: Signature: Title: Signature: On this day of 20, the application for a Nevada State Liquor License for has been Approved Denied American LegalNet, Inc. www.FormsWorkFlow.com 4 LTD 06 Revision Date 1 COUNTY COMMISSIONERS APPROVAL PAGE For all Non-Incorporated Cities FOR OFFICIAL USE ONLY Remarks and recommendations by the County Commissioners: Board of County Commissioners: Chairman: Member: Member: [seal] Member: Member: ATTEST: , County Clerk On this day of 20, the application for a Nevada State Liquor License for has been Approved Denied American LegalNet, Inc. www.FormsWorkFlow.com 5 LTD 06 Revision Date NEVADA STATE LIQUOR LICENSE APPLICATION INSTRUCTIONS Complete pages one and two in their entirety with all applicable information, attach additional sheets if necessary. 1.Application is being submitted for: Check the box that applies, please note that 223Location Change224 and 223AdditionalLocation224 are valid options only for the entity that originally applied for the license. Include the Taxpayer ID numberissued by the Department of Taxation if applicable.2.Application is for: Check the type of license you are applying for.3.Importer/Wholesaler License Type: If you are applying for an Importer or Wholesaler license, check all that apply.4.Manufacturer License Type: If you are applying for a Manufacturer license, check all that apply.5.Business Type: Indicate the entity type as filed with the Secretary of State.6.Date Incorporated/Organized: Enter the date and state incorporated/organized.7.Anticipated Start Date of Location: Enter the date that you are planning the license to take effect. Please note:Business operation may not begin until a State of Nevada Liquor License has been issued by the Department ofTaxation. Include the Federal Employer Identification Number issued to you by the Internal Revenue Service.8.Name of Business: Enter the name as registered on the State Business License. Include a business telephone number.9.DBA: Enter the name you will be doing business as known by the public. Include a fax number if available.10.Business Address: Enter in the complete address of the entity (corporate address).11.Location of Operation: Enter the physical address licensed operations will be performed. This address must beregistered and reflected on the permit issued by the Federal Alcohol and Tobacco Tax and Trade Bureau (TTB).12.Mailing Address: Enter the mailing address. This address will be used to mail license, reports, tax returns andcorrespondence.13.Email Address: Enter email (Internet) address information.14.List All Owners, Officers, Members, Partners, etc.: Include the full name, title, social security number, address,and percentage of ownership of each owner, officer, member, partner, etc. for the business.15.If Partnership, is the Agreement Recorded: If your business is a partnership please select yes or no. If yes, includewhere it was recorded.16.Operating under a Fictitious Firm Name: Select yes or no. If yes, include where it was recorded. A copy of thefictitious firm name certificate must be supplied to the Department of Taxation, per NRS 602.010.17.Has applicant applied for a local County or City License: Select yes or no. If yes, include where.18.Has applicant secured all necessary Federal permits: Select yes or no. If yes, enter the permit number issued bythe TTB. Provide a copy of the permit with this application.19.Is the location of operation