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 _____ Carrier –beer,wine,liquor NON REFUNDABLE $100.00 PROCESSING FEE TO BE MAILED WITH THIS REQUEST: 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 _______________________________________ PLEASE FILL OUT SECOND PAGE IN FULL American LegalNet, Inc. www.FormsWorkflow.com ___________________________________________________________ ________________________________________________ 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