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 INDIVIDUAL RETAIL LICENSEE INFORMATION FORM This application must be completed in full by EACH cooperative member. It should be submitted to the Division of Alcoholic Beverage Control in company with a Cooperative Group Application form which has been completed and signed by an officer of the Cooperative Group. Each member should submit a fee of $15.00 (payable by check or money order) at the time of application. ACTION REQUESTED: (Check One) ______ Renew Membership in Cooperative Group ______ New Membership in Cooperative Group ______________ ______________ ______ Delete Membership in Cooperative Group ______________ License Name_____________________________________________________ 12-Digit License Number__________________________________________ Address of Licensed Premises: Street___________________________________________________ City ______________________________ Zip_________________ )________-_________ Telephone No. ( Signature of Licensee____________________________________ Print Name____________________________________ Title____________________________________ Date____________________________________ Please note, this application must be signed by licensee if an individual; by a general partner if a partnership, general or limited; or by a corporate president or vice president if a corporation. 07/03 American LegalNet, Inc. www.FormsWorkflow.com