STATE OF NEW YORK LIQUOR AUTHORITY APPLICATION FOR A CHANGE IN CLASS FOR OFF-PREMISES BEER OR OFF-PREMISES BEER/WINE PRODUCT LICENSE THREE (3) YEAR LICENSE NAME OF LICENSEE__________________________________________________________________ ADDRESS OF LICENSED PREMISES_____________________________________________________ CURRENT LICENSE SERIAL NO.________________________________________________________ CURRENT LICENSE CERTIFICATION NO._________________________________________________ EFFECTIVE/EXPIRATION DATE OF CURRENT LICENSE______________TO____________________ This form is to be filled out completely and submitted to the Liquor Authority Zone Office where premises are located. CHECK ONE BOX ‫ٱ‬ To convert from Off-Premises Beer to an Off Premises Beer/Wine Product License submit the following additional information: a. An additional Fee to bring current license up to date – The fee is calculated at $7.50 per month for the remaining months on your current license. ‫ ٱ‬To convert from Off Premises Beer/Wine Product to Off Premises Beer ONLY Upon the satisfactory completion and submission of the above items, your application for a new license will be processed. When you have been notified that your application has been approved, please submit the following: 1. If from Grocery Store Beer to Beer/Wine Product a. Submit current license 2. If from Grocery Store Beer/Wine Product to Beer only – Upon renewal, your license will reflect Grocery “A” Off Premises Beer. There will be no refund given on the current license in effect. NOTE: Applications to convert from Grocery Store Beer/Wine Product to Grocery Store Beer only must be mailed to: PO BOX 3817, Church Street Station, New York, NY 10008-3817 3 months prior to the expiration of the current license. If not submitted 3 months prior to the expiration, the change will not take effect until the next renewal period. THE FOLLOWING CERTIFICATION MUST BE SIGNED AND DATED BY INDIVIDUAL APPLICANT,EACH MEMBER OF PARTNERSHIP OR ONE OF THE CORPORATE PRINCIPALS. The undersigned, each for himself/herself, certifies that he/she is the applicant named, that he/she knows the contents of this application and the statements contained therein and the same are true of his/her own knowledge. Dated:______________________________________ ___________________________________________ ____________________________________________ ___________________________________________ ____________________________________________ ___________________________________________ ____________________________________________ (Signature of applicant or each partner) (Residence) (Home Phone) SLA Action APPROVED SLA Form #1029 (revised 9/13/11) DISAPPROVED SLA by ______________ Dated _____________________________ American LegalNet, Inc. www.FormsWorkFlow.com