Liquor Commission Division of Enforcement & Licensing P.O. Box 1795, 10 Commercial Street Concord, NH 03302-1795 Phone: (603) 271-3521 REQUEST FOR APPLICATION TYPE OF APPLICATION Liquor Commission Use Only LIQUOR WINE REPRESTATIVE Control No. District (Lic Spec) Territory # Date Reviewed SPI Date NON REFUNDABLE PROCESSING FEE TO BE MAILED WITH THIS REQUEST: $100 APPLICATION FEE $25 FOR LW REP ONLY NO APPLICATION FEE FOR RETAIL TOACCO ONLY CORP/LLC/LLP NAME Initials DATE FORMED MM/DD/YY APPLICANT NAME LAST FIRST DATE OF BIRTH HOME ADDRESS NO STREET CITY STATE ZIP TRADE NAME LOCATION FOR LICENSE NO STREET CITY COUNTY STATE ZIP MAILING ADDRESS NO STREET CITY STATE BUSINESS PHONE ZIP HOME PHONE E-MAIL ADDRESS IS THIS A SINGLE PROP PARTNERSHIP/LLP CORPORATION LLC IF NON-NH, WHAT STATE CHARTERED IN: APPLICANT OWNS LEASES RENTS PREMISES HAS APPLICANT PREVIOUSLY OWNED/HAD INTEREST IN ANY LIQUOR LICENSE IF YES, WHEN GIVE LICENSE NO. YES NO AND NAME I UNDERSTAND THE REQUIREMENT OF TRAINING WITHIN 45 DAYS OF LICENSING. INCOMPLETE APPLICATIONS MAY DELAY LICENSING. AN ACCURATE MAILING ADDRESS WILL ENSURE YOU RECEIVE CRITICAL CORRESPONDENCE AND RENEWAL APPLICATIONS IN A TIMELY MANNER. I FURTHER UNDERSTAND THAT IF I FAIL TO COMPLY WITH THE TRAINING REQUIREMENT, MY LIQUOR LICENSE WILL BE SUSPENDED 45 DAYS AFTER ITS ISSUANCE AND REMAIN SUSPENDED UNTIL SUCH TIME AS I MEET THE TRAINING REQUIREMENTS. PLEASE CALL (603)271-8531 FOR FURTHER DETAILS OR VISIT US ON THE WEB @ www.nh.gov/liquor Signature Date of Request: Date Lic Specialist Signature L-001 (Reviewed 8/31/10) American LegalNet, Inc. www.FormsWorkFlow.com Last Name First Name Mr. / Ms. Maiden Name Title (Pres., Mbr., etc.) State Zip Address Home Phone Race Male Social Security # /Alien Reg. # D.O.B. Drivers License # Female P.O.B. Height Weight Mother’s Last Name Mother’s First Name Father’s Last Name Eye Hair Father’s First Name Last Name First Name Mr. / Ms. Maiden Name Title (Pres., Mbr., etc.) State Zip Address Home Phone Race Maiden Name Male Social Security # /Alien Reg. # D.O.B. Drivers License # Female P.O.B. Height Weight Mother’s Last Name Mother’s First Name Father’s Last Name Eye Hair Father’s First Name Last Name First Name Mr. / Ms. Maiden Name Title (Pres., Mbr., etc.) State Zip Address Home Phone Race Drivers License # Maiden Name Male Social Security # /Alien Reg. # D.O.B. Female P.O.B. Height Mother’s Last Name Mother’s First Name Father’s Last Name Weight Eye Hair Maiden Name Father’s First Name L-001 a American LegalNet, Inc. www.FormsWorkFlow.com