JON S. CORZINE GOVERNOR STATE OF NEW JERSEY OFFICE OF THE ATTORNEY GENERAL ANNE MILGRAM DEPARTMENT OF LAW AND PUBLIC SAFETY DIVISION OF ALCOHOLIC BEVERAGE CONTROL ATTORNEY GENERAL JERRY FISCHER P.O. BOX 087 DIRECTOR TRENTON, NJ 08625-0087 PHONE: (609) 984-2830 FAX: (609) 633-6078 HTTP://WWW.NJ.GOV/LPS/ABC SOLICITOR’S PERMIT PROCESSING The following procedures must be completed when applying for a Solicitor’s Permit: APPLICATION Section I must be completed by the employing wholesaler. All questions on Section II must be answered by the applicant. If applicant will be employed by two or more wholesalers within the same year or has previously been employed by a licensed New Jersey wholesaler, each company’s name and license number must be listed in Question 3. The signatures of the applicant and an authorized representative of the employing wholesaler are required in the notarized statement in Section III. FINGERPRINTS All candidates for Solicitor’s Permits must comply with the procedure for obtaining fingerprint impressions. (See attached form for fingerprint instructions.) Solicitors out of the industry for at least three years must be reprinted. PHOTOGRAPHS Each original application must be accompanied by one (1) passport size (2" X 2") photograph of the applicant. OVER / 140 EAST FRONT STREET, P.O. BOX 087, TRENTON, NEW JERSEY 08625-0087 NEW JERSEY IS AN EQUAL OPPORTUNITY EMPLOYER • PRINTED ON RECYCLED PAPER AND RECYCLABLE American LegalNet, Inc. www.FormsWorkflow.com FEES The fees for Solicitor’s Permits are as follows: $15.00 for those employed by SBD licensees and $25.00 for those employed by all other wholesale licensees. A wholesale employer’s company check may be submitted to the Division for payment of the Solicitor’s Permit fee. Otherwise, a personal check or money order is acceptable. Please make check or money order payable to the Division of Alcoholic Beverage Control. NOTE: Upon termination of employment, the solicitor or his employer must surrender the original Solicitor’s Permit to our Bureau for cancellation. If the solicitor commences employment with another wholesale licensee, he/she must apply for a new Solicitor’s Permit by submitting a new application, fee and passport photograph to this Division. 04/2004 American LegalNet, Inc. www.FormsWorkflow.com Revised 11/19/07 STATE OF NEW JERSEY DEPARTMENT OF LAW AND PUBLIC SAFETY DIVISION OF ALCOHOLIC BEVERAGE CONTROL P.O. BOX 087, 140 EAST FRONT STREET TRENTON, NJ 08625-0087 APPLICATION FOR SOLICITOR=S PERMIT A.B.C. USE ONLY SOLICITOR NO._______________________________ DATE ____________/____________/____________ THIS APPLICATION CONSISTS OF FOUR (4) PAGES WHICH MUST BE FULLY COMPLETED. __________________________________________________________________________________ SECTION I: TO BE COMPLETED BY NEW JERSEY WHOLESALE LICENSEE 1. Employer’s New Jersey License Number: __________-______-__________-___________ 2. License Name:_________________________________________________________________ 3. License Address:______________________________________________________________ (Street) ______________________________________________________________ (City) (State) (Zip Code) 4. Contact Name:_________________________ 5. Contact Phone #____________________ 6. Type(s) of Compensation Received by Applicant: Salary [ Commission [ Bonus [ Expenses [ Percentage [ No Compensation [ ] ] ] ] ] ] 7. Date Employment will Commence: _______/____/_______ Month Day Year __________________________________________________________________________________ SECTION II: TO BE COMPLETED BY APPLICANT 8. Solicitor Name:_______________________________________________________________ (Last) (First) (Middle) 9. Home Address:_________________________________________________________________ (Number/PO Box) (Street) _________________________________________________________________ (City) (State) (Zip Code) 10. Mailing Address:______________________________________________________________ (If Different) (Number/PO Box) (Street) ______________________________________________________________ (City) (State) (Zip Code) American LegalNet, Inc. www.FormsWorkflow.com 11. Telephone Number (______)__________________ 12. Date of Birth _______/_____/_______ Month Day Year 13. Social Security No: ___ ___ ___-___ ___-___ ___ ___ ___ 14. Drivers License No.: ________________/_______________________________________ (State) (Number) 15. Have you been previously employed by a New Jersey wholesale licensee? Yes ( ) No ( ) If yes, please provide the following information. List each previous employer individually (use extra paper if necessary): A. Wholesaler’s Name:_______________________________________________________ Dates Employed: FROM [_____]/[_____] TO [_____]/[_____] Month Year Month Year B. Wholesaler’s Name:_______________________________________________________ Dates Employed: FROM [_____]/[_____] TO [_____]/[_____] Month Year Month Year 16. Do you presently hold, or have you ever held, an interest, directly or indirectly, in any type of alcoholic beverage license in the United States, or are you receiving any payments from the sale of an alcoholic beverage license in the United States? Yes [ A. ] No [ ] If yes, please provide the following: State of Issue_____________________ Name of Licensed Entity____________________ License No.____________________ B. C. Indicate if your interest has been : D. 17. Type of License: Retail Wholesale/Supplier Manufacturer [ [ [ ] ] ] Date interest was terminated: ________/________ Month Year Surrendered Revoked Canceled Transferred Lapsed [ [ [ [ [ ] ] ] ] ] Are you currently a member of a Municipal Alcoholic Beverage License Issuing Authority in the State of New Jersey? Yes ( ) No ( ) If yes: Municipality______________________________________ County____________________________________________ Position__________________________________________ American LegalNet, Inc. www.FormsWorkflow.com 18. Do you currently hold any official position related to law enforcement in the State of New Jersey? Yes ( ) No ( ) If yes: Jurisdiction______________________________________ Title_____________________________________________ 19. Have you ever been denied a New Jersey Solicitor’s Permit? Yes ( ) No ( ) If yes, on what date and for what wholesaler had you been contracted to solicit? ___________________________ (Date) ____________________________________________ (Wholesaler/Employer) 20. Are you being investigated or have you ever been convicted of a violation of any law or regulation, etc., concerning the manufacture, sale, possession, distribution or transportation of alcoholic beverages? Yes ( ) No ( ) 21. Are you being investigated or have you ever been convicted of any criminal matter of any type whatsoever? Yes ( ) No ( ) If yes: Nature of Offense_____________________________________________________ Penalty (or status of investigation)___________________________________________ Date of Conviction ______/______/______ Jurisdiction: Federal [ ] State [ ] County [ ] Municipal [ ] Identify Jurisdiction:________________________________________________________ 22. If you answered “YES” to Question 20 or 21, have you petitioned the Director of the Division of Alcoholic Beverage Control for a disqualification removal/eligibility? Yes ( ) No ( ) If Granted: Docket No.__________________ Date of Determination ____/____/____ ***Please note statement #3 of the enclosed affidavit (page 4). If you are unable to attest to the truth of statement #3, do not sign the affidavit. You must provide a written explanation to the Division of Alcoholic Beverage Control which: 1. Lists the names of immediate family members, defined as husband, wife, son, daughter, grandson, granddaughter, brother, sister, father, mother, brother-in-law, sister-in-law, son-in-law or daughter-in-law that have any direct or indirect financial interest or participates in the operation of a retail alcoholic beverage license; and 2. Lists the license number(s) in which your immediate family member(s) have any direct or indirect financial interest in or participate in the operation of and 3. Whether you are claiming an exemption to N.J.A.C. 13:2-16.11 and the basis for your claim. American LegalNet, Inc. www.FormsWorkflow.com _____________________________________________________________________________ SECTION III: AFFIDAVIT - TO BE COMPLETED BY LICENSEE AND APPLICANT. ALSO TO BE NOTARIZED BY A NOTARY PUBLIC OR ATTORNEY AT LAW OF THE STATE OF NEW JERSEY STATE OF__________________________ ) ) COUNTY OF_________________________ ) The applicant specifically avers the following: 1. I do not presently have an interest, directly or indirectly, in any type of alcoholic beverage license other than described in question number 16 of my Solicitor’s Permit Application; and 2. No immediate family member of mine, meaning husband, wife, son, daughter, grandson, granddaughter, brother, sister, father, mother, brother-in-law, sister-in-law, son-in-law or daughter-in-law has any direct or indirect financial interest or participates in the operation of a retail alcoholic beverage license. 3. I am aware of my continuing obligation to report to the Division of Alcoholic Beverage Control any changes to the facts contained in my Solicitor’s Permit application. _________________________________ SIGNATURE OF APPLICANT _____________________________________________ AUTHORIZED SIGNATURE OF LICENSEE ________________________________ PRINT NAME OF APPLICANT ______________________________________________ PRINT NAME OF LICENSEE The above persons, being duly sworn according to law, upon their oaths, depose and state that the answers, statements and declarations made in the foregoing application are true to the best of their knowledge and belief and are aware that if any of the foregoing answers, statements or declarations are willfully false, they will be subject to punishment. SWORN TO BEFORE ME AND SUBSCRIBED IN MY PRESENCE THIS_______________ DAY OF ____________________________, 20_______ ______________________________________________ NOTARY PUBLIC OR OFFICER ADMINISTERING OATH American LegalNet, Inc. www.FormsWorkflow.com