State of New Hampshire Liquor Commission Division of Enforcement & Licensing AFFIDAVIT This affidavit is filed with the Liquor Commission’s Division of Enforcement & Licensing in support of my ownership, management control, employment by a business licensed, or applying for a license to sell alcoholic beverages and tobacco under Chapter 178 of the Revised Statutes Annotated. I, being duly sworn do depose and say: (Print Name) 1. Business Trade Name: Liquor Lic# Address (No. – Street) (City / Town) (State) (Zip) (No. – Street) (City / Town) (State) (Zip) (No. – Street) (City / Town) (State) (Zip) Mailing Address 2. 3. I live at: I was born in on (POB: i.e. State, or Province if Canada, Country if foreign) Home phone I am 4. Male Female (Date of Birth) Race (Age) Soc. Sec # I am not a citizen of the United States If not a citizen, R.A. Document # or other Identification submitted 5. I understand RSA 178:4 & RSA 179:23, IV, prohibit convicted felons from holding a license to sell alcohol or assuming control of licensed premise. By signing this affidavit I swear this information is true and accurate and that this document is signed under the penalty if false swearing (RSA 641:2) 6. Have you ever been charged with a crime? Yes No If yes, were you convicted of a felony? Yes No 7. I am filing this document in support of my employment as a Corporate Officer POA Person in Charge Partner LLC Member Proprietor LLC Manager Manager Title/Position RSA 179:23, IV requires the licensee to designate one or more people to be in charge of the premise in the licensee’ absence. 8. I swear before the Justice of Peace or Notary Public that this information is true and accurate, and that this document is signed under the penalty if false swearing (RSA 641:2) Signature Date County SS. Personally appeared before me and made oath that the same is true. known to be the person who executed (Affiant Name) SEAL L-002 (Reviewed 8/8/2012) Date: Justice of Peace / Notary Public 8/2006 American LegalNet, Inc. www.FormsWorkFlow.com