STATE LIQUOR COMMISSION STATE OF NEW HAMPSHIRE PO BOX 1795 CONCORD, NH 03302-1795 271-3521 REQUEST FOR APPLICATION FOR LICENSE CONTROL NO.__________________ DISTRICT (LIC SPEC)__________ TERRITORY # ____________ LICENSE TYPE(beer,wine,liq,lounge)________ SPI DATE_________________ TYPE OF APPLICATION _____BEVERAGE VENDOR__________________________ NON REFUNDABLE PROCESSING FEE TO BE MAILED WITH THIS REQUEST: $100 FOR REQUEST FOR APPLICATION CORP/LLC NAME _________________________________________________ __________________________ DATE OF INCORP/LLC. M/D/Y APPLICANT NAME ________________________________________________ __________________ LAST FIRST DATE OF BIRTH HOME ADDRESS ________________ ________________________________________________________________ NO. STREET _______________________________ CITY TRADE NAME ______________________________________________ STATE & ZIP ___________________________________________________________________________________ LOCATION FOR LICENSE _____________ NO. _____________________________________________________________ STREET ______________________________ ______________ _______________________________________ CITY COUNTY STATE & ZIP MAILING ADDRESS ___________________________________________________________________________________ NO. & STREET _____________________________________ CITY ________________________________________ STATE & ZIP IS THIS A SINGLE PROP?____________PARTNERSHIP?_____________CORPORATION?____________LLC?__________ IF CORP., WHAT STATE CHARTERED IN? _________________________________________________________________ APPLICANT: 1. OWNS _______________ 2. LEASES __________________ 3. RENTS ____________________ PREMISES. HAS APPLICANT PREVIOUSLY OWNED/HAD INTEREST IN ANY LIQUOR LICENSE_________WHEN______________ IF YES :GIVE LICENSE NO. ______________ AND NAME___________________________________________________ PHONE NUMBER YOU MAY BE REACHED AT ____________________________________ E-MAIL ADDRESS: ___________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com MUST BE COMPLETED IN FULL AND RETURNED WITH REQUEST FOR APPLICATION __________________________________________ ________________________________________________ Name: Mr./Mrs. Title(Pres,Mbr etc..) _______________________________________ __________________________ ______________________ Address: State Zip ______________ Home Phone ____________________________________ M F ________ ___________ ____________ Social Security #/Alien Reg. # Sex Race DOB POB ____________________________ ____________ _____________ ______________ ___________________ Drivers Lic # Hgt. Wght. Eye Hair __________________________________________ ___________________________________________ Mothers Name Maiden name: ____________________________________________ ___________________________________________ Fathers Name __________________________________________ ________________________________________________ Name: Mr./Mrs. Title(Pres,Mbr etc..) _______________________________________ __________________________ ______________________ Address: State Zip ______________ Home Phone ____________________________________ M F ________ ___________ ____________ Social Security #/Alien Reg. # Sex Race DOB POB ____________________________ ____________ _____________ ______________ ___________________ Drivers Lic # Hgt. Wght. Eye Hair __________________________________________ ___________________________________________ Mothers Name Maiden name: ____________________________________________ ___________________________________________ Fathers Name __________________________________________ ________________________________________________ Name: Mr./Mrs. Title(Pres,Mbr etc..) _______________________________________ __________________________ ______________________ Address: State Zip ______________ Home Phone ____________________________________ M F ________ ___________ ____________ Social Security #/Alien Reg. # Sex Race DOB POB ____________________________ ____________ _____________ ______________ Drivers Lic # Hgt. Wght. Eye ___________________ Hair __________________________________________ ___________________________________________ Mothers Name Maiden name: ____________________________________________ ___________________________________________ Fathers Name American LegalNet, Inc. www.FormsWorkflow.com