Division of ALCOHOLIC BEVERAGE CONTROL 140 East Front Street, P.O. Box 087, Trenton, New Jersey 08625-0087 APPLICATION FOR RETAIL ALCOHOLIC BEVERAGE LICENSE Applicants should complete the application in full. Where a question is not applicable, please enter the letters “N/A.” Where additional pages are necessary, you may photocopy any part of this application. A complete application is required whenever any of the following is requested: New License; Person-to-Person Transfer; Place-to-Place Transfer (including expansion of premises); Partnership changes (except Limited Partnerships); Change of Corporate Structure (of more than 33 1/3% interest); Extension to Administrator, Executor, Receiver, Trustee in Bankruptcy; License Renewal (unless an alternate application is provided by the Division of ABC) OR When required by the Division or the Local Issuing Authority. If you are reporting a change in facts about your license which does not involve one of the above transactions, complete Page 1 and any page[s] of the application on which information to be changed appears. You must also complete a Certification Page (Page 11). The original and two copies of the completed application, or pages reporting changes, should be submitted to the MUNICIPAL CLERK or BOARD OF ALCOHOLIC BEVERAGE CONTROL SECRETARY of the Municipality which will act on the request. It is the responsibility of the applicant to provide the required copies of the license application. One copy of the application should be returned to the applicant by the Municipality. It should be maintained with other records and available for inspection on the licensed premises. All fees are to accompany the application at the time of filing with the local issuing authority. A $200.00 filing fee, in the form of a CERTIFIED CHECK or MONEY ORDER – payable to the Division of Alcoholic Beverage Control – should accompany all applications for New Licenses, License Transfers or License Renewals. Local licensing fees are established by the Local Issuing Authority; consult the Municipal Clerk or ABC Board Secretary for information in this regard. L PS New Jersey Department of Law & Public Safety American LegalNet, Inc. www.FormsWorkFlow.com TR#: FEE: _____________________ _____________________ STATE OF NEW JERSEY DEPARTMENT OF LAW AND PUBLIC SAFETY DIVISION OF ALCOHOLIC BEVERAGE CONTROL DATE: _____________________ [ Action ID Code [ ] [ ] [ ] A W D U ] RETAIL LIQUOR LICENSE APPLICATION STATE ASSIGNED LICENSE NUMBER DATE APPLICATION FILED: ______ - ______ - ______ - ______ _____ / _____ / _____ [For DIVISION use only _________ ] CODE TYPE OF LICENSE (CHECK ONE) THIS APPLICATION IS FOR: CLASS C LICENSES [R.S. 33:1-12] 31 _____ Club _____ A New License 32 _____ Plenary Retail Consumption w/Broad Package Privilege 33 _____ Plenary Retail Consumption 36 _____ Plenary Retail Consumption (Hotel/Motel Exception) 37 _____ Plenary Retail Consumption (Theatre Exception) 35 _____ Seasonal Retail Consumption (November 15 through April 30) 34 _____ Seasonal Retail Consumption (May 1 through November 14) 44 _____ Plenary Retail Distribution 43 _____ Limited Retail Distribution Person-to-Person Transfer (Including Partnership change, except Limited Partnership) _____ Place-to-Place Transfer (Including expansion of premises) _____ Change of Corporate Structure _____ Extension of License (to Executor, Receiver, Administrator, etc.) _____ Renewal of License _____ Amendment of Application on File _____ Other ___________________________ ______________________________________ OTHER 14 _____ Annual State Permit (R.S. 33:1-42, NJAC 13:2-52) 40 _____ Special Permit for a Golf Facility (NJAC 13:2-5.3) ____________________________________________________________________________________________________________ This Area is Reserved for Municipal Use Municipal Fee $_________________ Effective Date _______ / _______ / _______ (As Stated in Resolution. Date of resolution unless otherwise established.) State Fee $_________________ Date Denied _______ / _______ / _______ (As Stated in Resolution) Refund Amount $________________ Special Conditions Attached: _______ Yes _______ No ____________________________________________________________________________________________________________ Type or Print Name (Last Name, First Name, Middle Initial) of Municipal Clerk or ABC Secretary ____________________________________________________________________________________________________________ Signature of Municipal Clerk or ABC Secretary American LegalNet, Inc. www.FormsWorkFlow.com Page 2 PLEASE TYPE OR PRINT ALL INFORMATION STATE ASSIGNED LICENSE NUMBER _______ - _______ - _______ - _______ Application is made on behalf of: ________ 1 = An Individual 3 = A Partnership 5 = Incorporated Club 2.1 2 = Business Corporation 4 = Unincorporated Club 6 = Limited Partnership 7 = Limited Liability Company NAME(S) AS IT DOES OR WILL APPEAR ON THE LICENSE CERTIFICATE (NOT “TRADE” NAME): License may be held by Individual (Last Name, First Name, Middle Initial), Partnership or Corporation. ____________________________________________________________________________________________________ (Last Name, First Name, Middle Initial or Corporate Name) 2.2 ACTUAL ADDRESS WHERE THE LICENSE IS TO BE USED (SITED PREMISES): Street Address _______________________________________________________________________________________ Number Street Name Municipality ________________________________________________________________ Telephone number of business 2.3 Zip __________ - _________ ( _______ ) _______________ - _______________ Area Exchange Number If no licensed premises exists or if a mailing address is different than the “actual address” given above, provide the mailing addres (insert N/A if not applicable): Street Address _______________________________________________________________________________________ Number Street Name P.O. Box # __________ Municipality _______________________________________ State ________________ Zip __________ - __________ Telephone ( _____ ) _______ - _______ 2.4 New Jersey Sales Tax Certificate of Authority No. ____________________________________________________________ 2.5 TRADE NAME(S) UNDER WHICH BUSINESS IS TO BE CONDUCTED. ALL TRADE NAMES MUST BE LISTED AND REGISTERED WITH THE N.J. SECRETARY OF STATE [if a corporation] OR COUNTY CLERK [if a partnership or sole proprietor]: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 2.6 THE FOLLOWING QUESTIONS ARE TO BE ANSWERED BY ALL APPLICANTS OTHER THAN APPLICANTS FOR A NEW LICENSE: A. IS THE LICENSE ACTIVELY USED AT AN OPERATING PLACE OF BUSINESS? __________ Yes __________ No B. IF NO, GIVE THE DATE THE BUSINESS STOPPED OPERATING (OR THE DATE THE LICENSE WAS ORIGINALLY ISSUED IF NEVER SITED AT AN OPERATING BUSINESS): __________ / __________ / __________ C. IF THE LICENSE IS INACTIVE AND THE APPLICATION IS FOR A TRANSFER, WILL THE LICENSE BE USED AT AN OPERATING PLACE OF BUSINESS AFTER APPROVAL? __________ Yes __________No 2.7 THE FOLLOWING QUESTIONS ARE TO BE ANSWERED BY AN APPLICANT FOR A NEW LICENSE: A. WILL THE LICENSE BE USED AT AN OPERATING PLACE OF BUSINESS IMMEDIATELY UPON ISSUANCE? __________ Yes __________No B. IF NO, PROVIDE ANTICIPATED DATE OF LICENSE ACTIVATION: __________ / __________ / __________ American LegalNet, Inc. www.FormsWorkFlow.com Page 3 PLEASE TYPE OR PRINT ALL INFORMATION STATE ASSIGNED LICENSE NUMBER _______ - _______ - _______ - _______ The following questions identify information about the licensed premises. This describes the area or place which is to be licensed for the sale, service, consumption, delivery, receipt or storage of alcoholic beverages. If the license is inactive and NOT SITED AT A PLACE OF BUSINESS, answer question 3.1 only, entering N/A for “not applicable.” [If you use N/A as a response to question 3.1, question 2.2 on Page 2 should also be answered N/A.] 3.1 HOW MANY SEPARATE BUILDINGS ARE TO BE INCLUDED UNDER THIS LICENSE? ____________ If more than one building is to be included under this license, a separate Page 3 is to be submitted covering each building. An up-to-date sketch of the entire licensed premises should be submitted for inclusion in the State ABC license file. 3.2 BUILDING NO. __________ OF __________ TO BE LICENSED. 3.3 IS THE ENTIRE BUILDING TO BE LICENSED? _________ Yes _________ No If the answer to question 3.3 is “No,” specify which floors are to be under license and which ones are not by answering the following questions: 3.4 Basement _____ Yes _____ No All of it _____ Yes _____ No _____ Yes _____ No All of it _____ Yes _____ No floor _____ Yes _____ No All of it _____ Yes _____ No 3 floor _____ Yes _____ No All of it _____ Yes _____ No st 1 floor nd 2 rd Specify each additional floor number to be included under this license: __________ If only part of any floor is to be licensed, attach a more detailed explanation with sketches to clearly delineate licensed areas from unlicensed areas. 3.5 ARE ANY GROUNDS ADJACENT TO THE BUILDING UNDER LICENSE TO BE INCLUDED AS PART OF THE LICENSED PREMISES? __________ Yes _________ No 3.6 IS THERE ANY UNLICENSED AREA LOCATED BETWEEN BUILDINGS UNDER THIS LICENSE OR BETWEEN LICENSED ADJACENT GROUNDS? __________ Yes _________ No IF THE ANSWER IS “YES,” ATTACH A SKETCH OF THE LICENSED AND UNLICENSED AREAS SHOWING DIMENSIONS IN FEET. 3.7 DOES THE APPLICANT OWN THE BUILDING? _____ Yes _____ No IF “YES,” IS THERE A MORTGAGE ON THE BUILDING? _____ Yes _____ No DOES THE APPLICANT LEASE THE BUILDING? _____ Yes _____ No If there is a mortgage on the property, answer question 3.8. If the licensed premise is leased, answer question 3.9. 3.8 MORTGAGEE (HOLDER OF MORTGAGE): ___________________________________________________________________________________________ (Last Name, First Name, Middle Initial or Corporate Name) Street Address ______________________________________________________________________________ Number Street Name P.O. Box # __________ Municipality _______________________________ State ___________________ Zip __________ - __________ 3.9 LANDLORD (HOLDER OF LEASE): ___________________________________________________________________________________________ (Last Name, First Name, Middle Initial or Corporate Name) Street Address ______________________________________________________________________________ Number Street Name P.O. Box # __________ Municipality ____________________________ State _____________________ Zip __________ - __________ American LegalNet, Inc. www.FormsWorkFlow.com Page 4 PLEASE TYPE OR PRINT ALL INFORMATION STATE ASSIGNED LICENSE NUMBER _______ - _______ - _______ - _______ 4.1 IS THE NEAREST ENTRANCE OF THE PLACE TO BE LICENSED WITHIN 200 FEET OF THE NEAREST ENTRANCE OF ANY CHURCH OR SCHOOL? _____ Yes _____ No IF THE ANSWER IS “YES,” IS A WAIVER SIGNED BY THE APPROPRIATE OFFICIAL ATTACHED TO THIS APPLICATION? _____ Yes _____ No 4.2 DOES THE APPLICANT INTEND TO USE ANY VEHICLES FOR THE TRANSPORT OR DELIVERY OF ALCOHOLIC BEVERAGES? _____ Yes _____ No (A TRANSIT INSIGNIA IS NECESSARY BEFORE ALCOHOLIC BEVERAGES MAY BE TRANSPORTED.) 4.3 HAS THE APPLICANT FILED AN ANNUAL SPECIAL TAX REGISTRATION AND RETURN FORM (TTB F 5630.5) WITH THE FEDERAL ALCOHOL AND TOBACCO TAX AND TRADE BUREAU? _____ Yes _____ No IF “YES,” DATE FILED _____ / _____ / _____ 4.4 WILL ANY BUSINESS OTHER THAN THE SALE OF ALCOHOLIC BEVERAGES BE CONDUCTED ON THE PREMISES TO BE LICENSED? _____ Yes _____ No IF THE ANSWER IS “YES,” INDICATE THE NATURE OF THE BUSINESS AND WHO WILL CONDUCT IT BY RESPONDING TO THE FOLLOWING QUESTIONS: _____ Restaurant _____ Applicant _____ Other _____ Catering _____ Applicant _____ Other _____ Hotel/Motel _____ Applicant _____ Other _____ Amusements _____ Applicant _____ Other _____ N.J. Lottery _____ Applicant _____ Other _____ Grocery or Delicatessen _____ Applicant _____ Other _____ Other (specify) _____ Applicant _____ Other 4.5 IF SOMEONE OTHER THAN THE APPLICANT WILL OPERATE THE OTHER BUSINESS ON THE LICENSED PREMISES, ANSWER THIS QUESTION. IF THERE IS MORE THAN ONE INDIVIDUAL OR COMPANY, ATTACH A SEPARATE PAGE LISTING THE REQUESTED INFORMATION FOR EACH OPERATOR. Business to be operated _______________________________________________________________ Name of company/individual ____________________________________________________________ (Last Name, First Name or Corporate Name) Street Address _______________________________________________________________________ Number Street Name Municipality ________________________________________ State ____________________________ Zip __________ - __________ NJ Sales Tax Certificate of Authority No. _______________________ American LegalNet, Inc. www.FormsWorkFlow.com Page 5 PLEASE TYPE OR PRINT ALL INFORMATION STATE ASSIGNED LICENSE NUMBER _______ - _______ - _______ - _______ ALL APPLICANTS ANSWER THE FOLLOWING 5.1 IS THE APPLICANT OR ANY OTHER PERSON MENTIONED IN THIS APPLICATION A POLICE OFFICER OR HOLD ANY POSITION ENTRUSTED WITH THE ENFORCEMENT OF ANY LAWS CONCERNING ALCOHOLIC BEVERAGES IN ANY MANNER WHATSOEVER? _____ Yes _____ No If the answer is “Yes,” complete the following: Name of individual ___________________________________________________________________ Last Name First Name Middle Initial Title of position held _________________________________________________________________ Name of Employing Agency ___________________________________________________________ 5.2 DOES THE APPLICANT OR ANY OTHER PERSON MENTIONED IN THIS APPLICATION, OR ANY PERSON HAVING A BENEFICIAL INTEREST IN THE LICENSED BUSINESS, HOLD OFFICE IN THE UNIT OF GOVERNMENT ISSUING THE LICENSE? _____ Yes _____ No IF THE ANSWER IS “YES,” COMPLETE THE FOLLOWING: Name of Individual _________________________________________________________________ Last Name First Name Middle Initial Title of Office _______________________________________________________________________ Municipality ________________________________________________________________________ 5.3 DOES THE APPLICANT OR ANY OTHER PERSON MENTIONED IN THIS LICENSE APPLICATION, OR ANYONE WITH A BENEFICIAL INTEREST IN THE LICENSED BUSINESS, DIRECTLY OR INDIRECTLY, HAVE ANY INTEREST IN ANY BREWERY, WINERY, DISTILLERY, RECTIFYING AND BLENDING PLANT, IMPORTER OR WHOLESALE ALCOHOLIC BEVERAGE BUSINESS, AS OWNER, PART OWNER, LANDLORD, TENANT, MORTGAGE HOLDER OR AS A STOCKHOLDER, OFFICER, DIRECTOR, AGENT, EMPLOYEE OR OTHERWISE? _____ Yes _____ No IF THE ANSWER IS “YES,” ATTACH AN AFFIDAVIT EXPLAINING THE RELATIONSHIP AND NATURE OF THE INTEREST AND COMPLETE THE FOLLOWING: A. New Jersey license number, if applicable __________ - __________ - __________ B. IF THE BUSINESS DOES NOT HOLD A NEW JERSEY LIQUOR LICENSE, ANSWER THE FOLLOWING QUESTIONS: Name of entity conducting business (Corporation, Partnership or Individual) _______________________________________________________________________________ (Last Name, First Name, Middle Initial or Corporate Name) Street Address __________________________________________________________________ Number Street Name P.O. Box # __________ Municipality ________________________ State _________ Zip __________ - __________ Type of Business _______________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page 6 PLEASE TYPE OR PRINT ALL INFORMATION STATE ASSIGNED LICENSE NUMBER _______ - _______ - _______ - _______ ALL APPLICANTS ANSWER THE FOLLOWING 6.1 HAS THE APPLICANT EVER BEEN DENIED A LIQUOR LICENSE IN NEW JERSEY? _____ Yes _____ No IF THE ANSWER TO THIS QUESTION IS “YES,” ANSWER THE FOLOWING: Type of License or Permit Denied: _____ Retail _____ Warehouse _____ Wholesale _____ Manufacturer _____ Transportation Unit of Government which denied License or Permit: ______________________________________________________ Date of Denial (approximate if not known) __________ / __________ / __________ Reason for Denial _________________________________________________________________________________ 6.2 HAS ANY CORPORATION, PARTNERSHIP OR INDIVIDUAL MENTIONED IN THIS APPLICATION, OTHER THAN THE APPLICANT, BEEN DENIED A LIQUOR LICENSE OR PERMIT? _____ Yes _____ No IF THE ANSWER IS “YES,” ANSWER THE FOLLOWING: Name of Entity ____________________________________________________________________________________ Last Name First Name Middle Initial Type of License or Permit Denied: _____ Retail _____ Warehouse _____ Wholesale _____ Manufacturer _____ Transportation Unit of Government which denied License or Permit: ______________________________________________________ Date of Denial (approximate if not known) __________ / __________ / __________ Reason for Denial _________________________________________________________________________________ 6.3 HAS THE APPLICANT OR ANY OTHER PERSON, CORPORATION OR ENTITY MENTIONED IN THIS LICENSE APPLICATION, OR ANYONE WITH A BENEFICIAL INTEREST IN IT, HAD AN INTEREST IN A NEW JERSEY ALCOHOLIC BEVERAGE LICENSE WHICH WAS SURRENDERED, SUSPENDED OR HAD A PENALTY IMPOSED IN LIEU OF SUSPENSION, NOT RENEWED, REVOKED OR CANCELLED WITHIN THE 10 YEARS PRIOR TO THE DATE OF THIS APPLICATION? _____ Yes _____ No IF THE ANSWER IS “YES,” PROVIDE DETAILS OF EACH BELOW [Complete a separate Page 6 for each action]: Name of Individual ________________________________________________________________________ Last Name First Name Middle Initial DATE OF ACTION ________ / ________ / ________ DOCKET NO. _______________________________ PENALTY WAS IMPOSED BY: ______________________________________________________________ [Indicate whether by Division of ABC or identify Local Issuing Authority] PENALTY CONSISTED OF: ________ FINED $ _________________________________ [amount] ________ SUSPENDED ______________________________ (number of days) ________ NOT RENEWED _________ REVOKED ________ CANCELLED ________ OTHER [explain] _________________________________________________________________ ________________________________________________________________________________________ 6.4 HAS THE APPLICANT OR ANY OTHER PERSON OR CORPORATION MENTIONED IN THIS LICENSE APPLICATION, OR ANYONE WITH A BENEFICIAL INTEREST IN THE BUSINESS UNDER LICENSE OR TO BE LICENSED, EVER BEEN CONVICTED OF A CRIMINAL OFFENSE? _____ Yes _____ No A. IF THE ANSWER IS “YES,” ANSWER THE FOLLOWING: Name of Individual _____________________________________________________________________ Last Name First Name Middle Initial Date of Birth _______ / ________ / ________ Conviction Date _______ / _______ / _______ State __________________ Court of Jurisdiction __________________________________________ Description of offense (specific charge) _____________________________________________________ _____________________________________________________________________________________ Disposition (fine, penalty, etc.) ____________________________________________________________ _____________________________________________________________________________________ Nature of interest in entity to be licensed _____________________________________________________ B. If applicable, provide the date the Director of the N.J. Division of Alcoholic Beverage Control issued an order approving or disapproving disqualification removal: _______ / _______ / _______. (No license may be issued without an order from the Director of the Division of Alcoholic Beverage Control determining no disqualification or removing disqualification.) (See R.S. 33:1-31.2 and N.J.A.C. 13:2-15.) Provide Agency Docket No. :[NN]- __________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page 7 PLEASE TYPE OR PRINT ALL INFORMATION STATE ASSIGNED LICENSE NUMBER _______ - _______ - _______ - _______ ALL APPLICANTS OTHER THAN CLUB LICENSE ANSWER THE FOLLOWING 7.1 DOES THE APPLICANT, A MEMBER OF THE APPLICANT’S IMMEDIATE FAMILY (SPOUSE, CHILDREN, PARENTS, IN-LAWS OR SIBLINGS) OR ANY PERSON WITH A BENEFICIAL INTEREST IN THE SUBJECT LICENSE OF THIS APPLICATION, HAVE ANY INTEREST IN ANY OTHER NEW JERSEY ALCOHOLIC BEVERAGE LICENSE? _____ Yes _____ No IF THE ANSWER IS “YES,” COMPLETE THE FOLLOWING BY LISTING THE NEW JERSEY LIQUOR LICENSE TWELVE DIGIT NUMBER(S) AND THE NAME(S) OF THE PERSON(S) OR CORPORATION(S) WHO HOLD(S) SUCH INTEREST. USE ADDITIONAL PAGE(S) 7 AS NEEDED. A. License Number __________ - __________ - __________ - __________ Name ___________________________________________________________________________ (Last Name, First Name, Middle Initial or Corporate Name) Relationship to Applicant ____________________________________________________________ **************************************************************************************************************** B. License Number __________ - __________ - __________ - __________ Name ___________________________________________________________________________ (Last Name, First Name, Middle Initial or Corporate Name) Relationship to Applicant ____________________________________________________________ **************************************************************************************************************** C. License Number __________ - __________ - __________ - __________ Name ___________________________________________________________________________ (Last Name, First Name, Middle Initial or Corporate Name) Relationship to Applicant ____________________________________________________________ **************************************************************************************************************** 7.2 WOULD ANY PERSON OR CORPORATION NAMED IN THIS APPLICATION FAIL TO QUALIFY FOR OWNERSHIP OF THE LICENSE IF APPLYING AS AN INDIVIDUAL BECAUSE OF AGE, CRIMINAL CONVICTION OR PROHIBITED INTERESTS IN OTHER LICENSES? _____ Yes _____ No IF THE ANSWER IS “YES,” ANSWER THE FOLLOWING BY INSERTING THE NAME OF THE INDIVIDUAL OR CORPORATION AND THE SOCIAL SECURITY NUMBER AND DATE OF BIRTH, IF AN INDIVIDUAL. USE ADDITIONAL PAGE(S) 7 AS NEEDED. Name ______________________________________________________________________________ (Last Name, First Name, Middle Initial or Corporate Name) Social Security Number _________ - __________ - __________ OR NJ Sales Tax Certificate of Authority No. ___________________________________________________ Date of Birth __________ / __________ / __________ American LegalNet, Inc. www.FormsWorkFlow.com Page 8 PLEASE TYPE OR PRINT ALL INFORMATION STATE ASSIGNED LICENSE NUMBER _______ - _______ - _______ - _______ ALL APPLICANTS ANSWER THE FOLLOWING 8.1 DOES THE APPLICANT OR ANYONE MENTIONED IN THIS APPLICATION OWE THE STATE OF NEW JERSEY OR THE UNITED STATES ANY LICENSE FEE, PENALTY, INTEREST OR ALCOHOLIC BEVERAGE TAX WHICH HAS ACCRUED PURSUANT TO THE ALCOHOLIC BEVERAGE TAX LAW, THE ALCOHOLIC BEVERAGE LAW OR ANY OTHER NEW JERSEY OR FEDERAL LAW? _____ Yes _____ No 8.2 HAS THE LICENSE BEEN ISSUED, OR IS IT BEING REQUESTED TO BE ISSUED, FOR A HOTEL/MOTEL AS AN EXCEPTION TO THE POPULATION RESTRICTION UNDER THE PROVISIONS OF R.S. 33:1-12.20? _____ Yes _____ No IF THE ANSWER IS “YES,” IS IT FOR A HOTEL/MOTEL FACILITY OF 50 OR 100 ROOMS? CHECK ONE: _____ 50 ROOMS _____ 100 ROOMS 8.3 HAS THE LICENSE BEEN ISSUED, OR IS IT BEING REQUESTED TO BE ISSUED, AS AN EXCEPTION TO THE TWO LICENSE LIMITATION LAW (R.S. 33:1-12.32) FOR A HOTEL/MOTEL, RESTAURANT, BOWLING ALLEY OR INTERNATIONAL AIRPORT? _____ Yes _____ No IF THE ANSWER IS “YES,” CHECK ONE OF THE FOLLOWING: _____ HOTEL/MOTEL _____ RESTAURANT _____ BOWLING ALLEY _____ INTERNATIONAL AIRPORT THE FOLLOWING ARE TO BE ANSWERED WHEN APPLICATION IS FOR A LICENSE TRANSFER. 8.4 LICENSE NUMBER SOUGHT TO BE TRANSFERRED __________ - __________ - __________ - __________ 8.5 IF THIS IS A REQUEST FOR A PERSON-TO-PERSON TRANSFER, INSERT NAME(S) OF PERSON (Last Name First), PARTNERSHIP OR CORPORATION CURRENTLY HOLDING THE LICENSE: _____________________________________________________________________________________________ (Last Name, First Name, Middle Initial or Corporate Name) 8.6 IF THIS IS A REQUEST FOR A PLACE-TO-PLACE TRANSFER OF A POCKET LICENSE (NO SITED PREMISES), MARK AN X HERE: __________ IF THIS IS A REQUEST FOR A PLACE-TO-PLACE TRANSFER OF A SITED LICENSE, INSERT THE ADDRESS OF THE CURRENT SITE FROM WHICH THE LICENSE IS TO BE TRANSFERRED. Street Address _________________________________________________________________________________ Number Street Name Municipality ______________________________________________ New Jersey Zip _________ - __________ THE FOLLOWING ARE TO BE ANSWERED BY APPLICANTS FOR A NEW LICENSE OR A LICENSE TRANSFER. 8.7 INSERT THE ANTICIPATED DATES WHEN PUBLIC NOTICE OF APPLICATION WILL BE PUBLISHED. PUBLICATION MAY NOT BE SOONER THAN THE DATE OF FILING OF THIS APPLICATION. Date of first notice ________ / ________ / ________ Date of second notice ________ / ________ / ________ 8.8 NAME OF NEWSPAPER TO PUBLISH NOTICE ______________________________________________________ 8.9 THE FOLLOWING ARE TO BE ANSWERED BY CORPORATIONS REPORTING A CHANGE OF CORPORATE STRUCTURE WHEREIN A NEW STOCKHOLDER ACQUIRES MORE THAN 1 PERCENT OF THE STOCK OF THE LICENSED COMPANY (ONE PUBLICATION OF NOTICE REQUIRED). Date of notice ________ / ________ / ________ Name of newspaper publishing notice _______________________________________________________________ THE FOLLOWING QUESTIONS ARE FOR CLUB LICENSE APPLICANTS ONLY: 8.10 HAS THE CLUB BEEN IN ACTIVE OPERATION IN THE STATE OF NEW JERSEY FOR AT LEAST THREE YEARS CONTINUOUSLY IMMEDIATELY PRIOR TO THE SUBMISSION OF ITS APPLICATION FOR A LICENSE? _____ Yes _____ No 8.11 IS THE APPLICANT A CONSTITUENT UNIT, CHARTERED OR OTHERWISE DULY ENFRANCISED CHAPTER OR MEMBER CLUB OF A NATIONAL OR STATE ORDER? _____ Yes _____ No 8.12 HAS THE CLUB HAD EXCLUSIVE POSSESSION AND USE OF CLUB QUARTERS FOR THREE CONTINUOUS YEARS? _____ Yes _____ No 8.13 DOES THE CLUB HAVE AT LEAST 60 VOTING MEMBERS? _____ Yes _____ No American LegalNet, Inc. www.FormsWorkFlow.com Page 9 PLEASE TYPE OR PRINT ALL INFORMATION STATE ASSIGNED LICENSE NUMBER _______ - _______ - _______ - _______ ALL APPLICANTS ANSWER THE FOLLOWING 9.1 DOES ANY INDIVIDUAL, PARTNERSHIP, CORPORATION OR ASSOCIATION OTHER THAN THE APPLICANT HAVE AN INTEREST DIRECTLY OR INDIRECTLY IN THE LICENSE APPLIED FOR OR IS THE STOCK OF ANY STOCKHOLDER HELD IN ESCROW OR PLEDGED IN ANY WAY? _____ Yes _____ No IF THE ANSWER IS “YES,” ANSWER THE FOLLOWING USING A SEPARATE PAGE 9 FOR EACH INDIVIDUAL OR CORPORATION OF INTEREST. ATTACH A SEPARATE PAGE OF EXPLANATION IF MORE SPACE IS NEEDED. Name of Individual (Last Name First) or Corporation ______________________________________________________________________________________________ (Last Name, First Name, Middle Initial or Corporate Name) Social Security Number __________ - __________ - __________ OR NJ Sales Tax Certificate of Authority Number __________________________________________________________ Street Address __________________________________________________________________________________ Number Street Name P.O. Box # __________ Municipality __________________________________ State ________________ Zip __________ - __________ Describe Nature of Interest ________________________________________________________________________ 9.2 DOES ANY INDIVIDUAL, PARTNERSHIP, CORPORATION OR ASSOCIATION HOLD ANY CHATTEL MORTGAGE OR CONDITIONAL BILL OF SALE OR OTHER SECURITY INTEREST ON ANY FURNITURE, FIXTURES, GOODS OR EQUIPMENT TO BE USED IN CONNECTION WITH THE BUSINESS TO BE OPERATED UNDER THE LICENSE APPLIED FOR? _____ Yes _____ No IF THE ANSWER IS “YES,” ANSWER THE FOLLOWING USING A SEPARATE PAGE 9 FOR EACH INDIVIDUAL OR CORPORATION TO BE REPORTED. ATTACH A SEPARATE PAGE OF EXPLANATION IF MORE SPACE IS NEEDED. Name of Individual (Last Name First) or Corporation _______________________________________________________________________________________________ (Last Name, First Name, Middle Initial or Corporate Name) Social Security Number __________ - __________ - __________ OR NJ Sales Tax Certificate of Authority Number __________________________________________________________ Street Address __________________________________________________________________________________ Number Street Name P.O. Box # __________ Municipality ____________________________ State _____________ Zip __________ - __________ Describe Nature of Interest ________________________________________________________________________ 9.3 HAS THE APPLICANT AGREED TO PERMIT ANYONE NOT HAVING AN OWNERSHIP INTEREST IN THE LICENSE TO RECEIVE OR AGREED TO PAY ANYONE (BY WAY OF RENT, SALARY OR OTHERWISE) ALL OR ANY PERCENTAGE OF THE GROSS RECEIPTS OR NET PROFIT OR INCOME DERIVED FROM THE BUSINESS TO BE CONDUCTED UNDER THE LICENSE APPLIED FOR? _____ Yes _____ No IF THE ANSWER IS “YES,” ANSWER THE FOLLOWING USING A SEPARATE PAGE 9 FOR EACH INDIVIDUAL OR CORPORATION TO BE REPORTED. ATTACH A SEPARATE PAGE OF EXPLANATION IF MORE SPACE IS NEEDED. Name of Individual (Last Name First) or Corporation _____________________________________________________________________________________________ Last Name First Name Middle Initial Social Security Number __________ - __________ - __________ OR NJ Sales Tax Certificate of Authority Number __________________________________________________________ Street Address _________________________________________________________________________________ Number Street Name P.O. Box # __________ Municipality _____________________________________ State ________________ Zip __________ - __________ Describe Nature of Interest ________________________________________________________________________ APPLICANTS THAT ARE SOLE PROPRIETORS OR PARTNERSHIPS GO TO PAGE 10A. CORPORATIONS AND LIMITED LIABILITY COMPANIES COMPLETE PAGE 10. American LegalNet, Inc. www.FormsWorkFlow.com Page 10 PLEASE TYPE OR PRINT ALL INFORMATION STATE ASSIGNED LICENSE NUMBER _______ - _______ - _______ - _______ QUESTIONS TO BE ANSWERED BY CORPORATIONS AND LIMITED LIABILITY COMPANIES ONLY. ANY CORPORATION OR LIMITED LIABILITY COMPANY THAT IS REPORTED TO HAVE AN INTEREST IN THE BUSINESS TO BE LICENSED, WHETHER THE LICENSEE COMPANY, THE PARENT CORPORATION OF THE LICENSED COMPANY, HOLDING COMPANY OR OTHERWISE AFFILIATED IN THE CORPORATE CHAIN, MUST ANSWER THE FOLLOWING USING A SEPARATE PAGE 10 AND PAGE 10A FOR EACH CORPORATION. ANSWER QUESTIONS ON BOTH PAGE 10 AND PAGE 10A FOR EACH CORPORATION. 10.1 Name of corporation ______________________________________________________________________________ 10.2 Street address of home office _______________________________________________________________________ Number Street Name Municipality _____________________________________________________________________________________ State _________________________ Zip __________ - __________ 10.3 NJ Sales Tax Certificate of Authority Number __________________________________________________________ 10.4 IF CORPORATION ADDRESS IN NUMBER 10.2 ABOVE IS OUT OF STATE, REPORT BELOW THE ADDRESS OF ANY OFFICE LOCATION IN NEW JERSEY. INSERT N/A IF NONE. Street Address __________________________________________________________________________________ Number Street Name Municipality _______________________________________ New Jersey Zip __________ - __________ 10.5 IS THE CORPORATION NOW AN EXISTING, VALID CORPORATION? _____ Yes _____ No 10.6 DATE CHARTERED OR INCORPORATED __________ / __________ / __________ STATE ___________________ 10.7 CERTIFICATE OF INCORPORATION NUMBER ________________________________________________________ 10.8 IF NOT INCORPORATED UNDER THE LAWS OF NEW JERSEY, HAS THE CORPORATION RECEIVED AN AUTHORIZATION TO CONDUCT BUSINESS IN NEW JERSEY FROM THE NEW JERSEY OFFICE OF THE SECRETARY OF STATE? _____ Yes _____ No 10.9 HAS THE CORPORATION CHARTER EVER BEEN REVOKED BY THE OFFICE OF THE SECRETARY OF STATE IN NEW JERSEY? _____ Yes _____ No IF THE ANSWER IS “YES,” INSERT THE DATE OF REVOCATION, OR IF SUSPENDED, THE BEGINNING AND ENDING DATE OF THE SUSPENSION. Date of revocation __________ / __________ / __________ Beginning date __________ / __________ / __________ Ending date __________ / __________ / __________ 10.10 INSERT THE NAME AND ADDRESS OF THE REGISTERED OR AUTHORIZED AGENT IN NEW JERSEY UPON WHOM SERVICE OF PROCESS IN ANY PROCEEDINGS AGAINST THE APPLICANT, PURSUANT TO THE NEW JERSEY ALCOHOLIC BEVERAGE LAW, THE ALCOHOLIC BEVERAGE TAX LAW OR PROCEEDINGS IN A STATE OR U.S. DISTRICT COURT, MAY BE MADE. Name __________________________________________________________________________________________ (Last Name, First Name, Middle Initial or Corporation) Street Address __________________________________________________________________________________ Number Street Name Municipality _______________________________________ New Jersey Zip __________ - __________ Telephone Number ( _________ ) ____________ - _______________ Area Exchange Number 10.11 IF THE LICENSED COMPANY IS OWNED BY OTHER CORPORATION(S) OR IS IN A CORPORATE CHAIN, ATTACH A DIAGRAM DEPICTING THE CORPORATE RELATIONSHIPS AND THE PERCENTAGE OF STOCK INTEREST IN THE COMPANY TO BE LICENSED, OWNED BY OTHER CORPORATIONS OR OTHER NON-CORPORATE ENTITITES (INDIVIDUALS, PARTNERSHIPS, ASSOCIATIONS). American LegalNet, Inc. www.FormsWorkFlow.com Page 10A PLEASE TYPE OR PRINT ALL INFORMATION STATE ASSIGNED LICENSE NUMBER _______ - _______ - _______ - _______ ALL APPLICANTS ANSWER THE FOLLOWING [ADD PAGES AS NECESSARY] SOLE OWNERS AND PARTNERSHIPS: Complete this page in full. LIMITED PARTNERSHIPS: All information about a general partner or partners of a limited partnership must be reported, whether the general partner is an individual or a corporation. A list of the names and addresses of all limited partners must be submitted as an attachment to this application with an identification of the percentage of each limited partner as it relates to total ownership of the business entity to be licensed. CORPORATIONS: All corporation applicants or licensees and any corporation that has an ownership interest in the corporation under license or to be licensed must have been reported on Page 10. Information on this Page, 10A, will identify all officers, directors and stockholders holding one percent or more of the shares of the respective company. Club licenses must list names of officers and directors and attach a current membership list. ******************************************************************************************************************* NAME OF CORPORATION OR CLUB COVERED BY THIS PAGE (COMPLETE ONLY IF APPLICANT OR STOCKHOLDER IS A CORPORATION OR PARTNERSHIP) ___________________________________________________________________________________________________________ Name of individual (last name first), stockholder, partner, officer or director: ___________________________________________________________________________________________________________ Last Name First Name Middle Initial Home Street Address _________________________________________________________________________________________ Number Street Name P.O. Box # __________ Municipality _____________________________________ State ________________ Zip __________ - __________ Social Security Number __________ - __________ - __________ Date of Birth __________ / __________ / __________ Home telephone number ( _________ ) ____________ - ____________ Area Exchange Number Office telephone number ( _________ ) ____________ - ____________ Area Exchange Number % of business owned or controlled _____________________________________ Number of shares __________________________ Check position that applies: _____ Sole owner _____ Partner _____ Stockholder _____ President _____ Vice-President _____ Secretary _____ Treasurer _____ Director _____ Trustee _____ Manager _____ Agent _____ Executor/Administrator _____ Receiver _____ Beneficiary _____ Other (specify) __________________________________________________________________ Name of individual (last name first) ___________________________________________________________________________________________________________ Last Name First Name Middle Initial Home Street Address _________________________________________________________________________________________ Number Street Name P.O. Box # __________ Municipality _____________________________________ State ________________ Zip __________ - __________ Social Security Number __________ - __________ - __________ Date of Birth __________ / __________ / __________ Home telephone number ( _________ ) ____________ - ____________ Area Exchange Number Office telephone number ( _________ ) ____________ - ____________ Area Exchange Number % of business owned or controlled _____________________________________ Number of shares __________________________ Check position that applies: _____ Sole owner _____ Partner _____ Stockholder _____ President _____ Vice-President _____ Secretary _____ Treasurer _____ Director _____ Trustee _____ Manager _____ Agent _____ Executor/Administrator _____ Receiver _____ Beneficiary _____ Other (specify) __________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page 11 PLEASE TYPE OR PRINT ALL INFORMATION STATE ASSIGNED LICENSE NUMBER _______ - _______ - _______ - _______ AFFIDAVIT LICENSE PERIOD APPLIED FOR DATE: FROM _______________ TO _______________ ) State of ___________________________________ ) ) County of __________________________________ ) ) As provided by law (R.S. 33:1-35), SS: (Check One) 1. The Individual Applicant 2. Members of the Partnership Applicant 3. __________________________________ of _______________________________________________ (President/Vice-President) (Corporation or Club Name) consent(s) that the licensed premises and all portions of the building constituting the licensed premises, including all rooms, cellars, closets, out-buildings, passageways, vaults, yards, attics and every part of the structure of which the licensed premises are a part and all buildings used in connection therewith which are in his/her/their possession or under his/her/their control, may be inspected and searched without warrant at all hours by the Director of the Division of Alcoholic Beverage Control, his or her duly authorized deputies, inspectors or investigators and all other sworn law enforcement officers, and being duly sworn according to law, upon his/her/their oath(s), depose(s) and say(s) that he/she is (they are) the person(s) duly authorized to sign the application, that in instance of corporate ownership, the signator is authorized by corporate resolution to sign on behalf of the corporations; and that the contents of this application represent complete disclosure of the fact, and that the contents of this application are true. _____________________________________________________ (Signature of Individual Agent / Sole Proprietor) (Corporations Only) Attestation by Corporate Secretary Attest: Secretary __________ Signature ____________________________________ (Partnership Name) ____________________________________ (Signature of Partner) ___________________________________________ Corporate Name ____________________________ (Signature of Partner) By __________________________________________ (Signature of Corporate President or Vice President) ___________________________________ (Signature of Partner) ___________________________________ (Signature of Partner) Affix Corporate Seal Sworn to and subscribed before me this ______________ day of _______________ 20 __________ AFFIDAVIT MUST BE SIGNED HERE ---------------► ________________________________________ (Signature of Officer Administering Oath) BY DULY AUTHORIZED NOTARY PUBLIC ____________________________________ (Printed Name of Officer Administering Oath) OR AN ATTORNEY-AT-LAW OF NEW JERSEY ____________________________________ (Title of Officer Administering Oath) ______________________ (Date of Expiration of Commission, if applicable) American LegalNet, Inc. www.FormsWorkFlow.com