OFFICE USE ONLY Original Amended 29 Date APPLICATION FOR ALCOHOLIC BEVERAGE CONTROL RETAIL LICENSE (ON PREMISES LIQUOR) It is not necessary to employ any person, agency or organization to assist you in filing this application. Beware of persons claiming to be able to assist you in securing action on your application. The payment of money or other thing of value for the use of influence, or promise of influence in obtaining a license is a violation of law and offenders will be prosecuted. 1. APPLICANT Name of Applicant: Trade Name(DBA): (see instructions) ** must be provided if premises will be called by any name other than as listed in the "Name of Applicant" Premises Street Address: City: State: Zip Code: County: Telephone Number of Premises (include area code): Between what streets: Mailing Address (if different than above): City: State: Zip Code: E-mail address (if available): 2. CONTACT Attorney Name of Contact: Representative Contact Person Office Address: City: State: Zip Code: Telephone Number of Office (include area code): E-mail address (if available): 3. For SEASONAL licenses only - beginning and ending months: 4. LICENSE CLASS: CODE: (see schedule of fees) 5. Number of ADDITIONAL BARS (if any): 6. TOTAL PAYMENT DUE: (see instructions) 7a. Federal Tax ID Number: [OFFICE USE ONLY] DATE FILED: 7b. Worker's Compensation/ Disability Benefits Carrier Name and Policy Number: SERIAL #: continued on next page Page 1 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Amended Original 29 Date 8. Are there any local option restrictions in this area (DRY, PARTIALLY DRY)? YES NO DO NOT KNOW If YES, explain: 9. TO BE FILLED IN ONLY BY INDIVIDUAL OR PARTNERS Name of Individual / Partner Residence Citizenship Date of Birth Name of Individual / Partner Residence Citizenship Date of Birth Name of Individual / Partner Residence Citizenship Date of Birth Name of Individual / Partner Residence Citizenship Date of Birth Name of Individual / Partner Residence Citizenship Date of Birth Statutory Disqualification: Identify and explain as described on page II of instructions 10. TO BE FILLED IN ONLY BY CORPORATION OR LLC/LLP APPLICANTS a. State under what law applicant was organized: b. Date of organization: (SUBMIT COPY OF FILING RECEIPT) c. If applicant is a foreign entity, has a Certificate of Authority been obtained to do business in this state? YES NO d. If YES, date of certificate: e. Mailing Address (if different from premises): City: State: Zip Code: continued on next page Page 2 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original Amended 29 Date 10. continued f. List the names and address or Principals (Stockholders, Officers, Directors, LLC Members/Managers, LLP Partners) Name of Principal Residence Citizenship Title No. of Shares if Corporation or % of ownership if LLC or Partnership Date of Birth Name of Principal Residence Citizenship Title No. of Shares if Corporation or % of ownership if LLC or Partnership Date of Birth Name of Principal Residence Citizenship Title No. of Shares if Corporation or % of ownership if LLC or Partnership Date of Birth Name of Principal Residence Citizenship Title No. of Shares if Corporation or % of ownership if LLC or Partnership Date of Birth Name of Principal Residence Citizenship Title No. of Shares if Corporation or % of ownership if LLC or Partnership Date of Birth Statutory Disqualification: Identify and explain as described on page II of instructions Page 3 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original Amended 29 Date RIGHT TO PREMISES 1. RIGHT TO PREMISES a. By what right does the applicant have possession of the premises? Own Lease Sub-Lease Binding contract to acquire real property Written intent to Lease Other (explain): b. Do the terms of the lease or other arrangement require the applicant to provide any consideration based on a percentage of the receipts of the business? YES NO If YES, state percentage and give details: c. Specify Lease Start Date: Specify Lease Expiration Date: 2. INTERESTED PARTIES a. Is there currently a license to traffic in alcoholic beverages in effect for the premises for which this application is filed? YES b. Name of current/previous licensee: NO Do Not Know License Serial Number: c. Are there any disciplinary actions pending against the applicant, current licensee, or prior licensee? YES NO Do Not Know Any pending disciplinary action may prevent a determination on this application or result in the disapproval of the application with or without prejudice. d. Does any person, corporate principal, LLC or LLP member, or any person not an officer, director, or stockholder of such corporation, or member of LLC or LLP, or any other person not identified herein share or will share on a percentage basis or in any way in the receipts, losses or deficiencies of the business to any extent whatsoever? YES NO If YES, state the names and address of such persons, the nature and percent of their share and date acquired. Name Address Nature of interest Date Acquired Name Address Nature of interest Date Acquired Name Address Nature of interest Date Acquired Name Address Nature of interest Date Acquired continued on next page Page 4 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original Amended Date 2. Continued e. Does the applicant or, if a partnership any of the partners, or if a corporation any of the officers, directors or stockholders or if a limited liability company (LLC), or a limited liability partnership (LLP) or its members have any interest, direct or indirect, in any other premises or business where any alcoholic beverage is manufactured or sold at wholesale or retail, whether by stock ownership, interlocking directors, mortgage or lien on, or ownership YES NO of any real or personal property, or by any other means including loans? If YES, state the name and address of the premises, the license number, the date the interest was acquired and the exact nature of the interest. Name Address Date Acquired Name Nature of interest Address Date Acquired Name Date Acquired Serial Number Serial Number Nature of interest Address Serial Number Nature of interest Page 5 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original Amended 48 Date LANDLORD IDENTIFICATION INFORMATION 1. Name of Landlord: 2. Mailing address of Landlord: 3. Telephone Number of Landlord: 4. Landlord Principals Name Address Name Address Name Address Name Address 5(a). Are any persons listed on this form currently or previously licensed under the ABC Law? 5(b). If YES, list the names and serial numbers: 6(a). Are any persons listed on this form police officers: 6(b). If YES, list the names : YES YES NO NO 7. List number of years real property has been owned by landlord: Signature of Landlord Date IMPORTANT: SIGNATURE MUST BE THE SAME AS SIGNATURE ON THE ORIGINAL LEASE. IF NOT, FURNISH EITHER AN AFFIDAVIT IN EXPLANATION, AFFIX LEGIBLE CORPORATE SEAL OR SUBMIT OTHER PROOF OF SIGNATURE'S AUTHORITY Page 6 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original Amended 28 Date LIST OF EXPENSES FOR THIS VENTURE Expense Item (Actual or Estimated) 1. Real Property: 2. Purchase/Contract price (submit copy of contract): 3. Security Deposit: 4. Operating Capital: 5. Miscellaneous Expenses (include Attorney/Representative fee): 6. SLA Fees: 7. First month's rent and any paid to date: 8. Renovations: 9. Other: (See Instructions for required verifications) 10. TOTAL CASH 11. TOTAL DEFERRED (Total deferred includes loans, mortgages, lines of credit, notes, etc. Attach copies of EACH source of deferred monies) Explain in detail how deferred 12. TOTAL COST NOTE: The amounts in items 1 through 9 must total the amount reflected in item 12. The amounts in items 10 and 11 must total the amount reflected in item 12. IMPORTANT: Submit any and all records, documents and affidavits including loan agreements that you feel may assist you in explaining the source of monies as per instruction sheet. List bank names and account numbers from which "total cash" will derive. continued on next page Page 7 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original Amended 28 Date List lenders and amounts (to be) loaned from which "total deferred" will derive. Dollar(s) Amount Type of Investment ( Accounts, Loans, Gifts, Asset Sales, etc.) Source of Funds (Identify by Name - Lender, Giftor, Asset Sales, etc. - Provide Personal Questionnaires) Dollar(s) Amount Type of Investment ( Accounts, Loans, Gifts, Asset Sales, etc.) Source of Funds (Identify by Name - Lender, Giftor, Asset Sales, etc. - Provide Personal Questionnaires) Dollar(s) Amount Type of Investment ( Accounts, Loans, Gifts, Asset Sales, etc.) Source of Funds (Identify by Name - Lender, Giftor, Asset Sales, etc. - Provide Personal Questionnaires) Dollar(s) Amount Type of Investment ( Accounts, Loans, Gifts, Asset Sales, etc.) Source of Funds (Identify by Name - Lender, Giftor, Asset Sales, etc. - Provide Personal Questionnaires) Dollar(s) Amount Type of Investment ( Accounts, Loans, Gifts, Asset Sales, etc.) Source of Funds (Identify by Name - Lender, Giftor, Asset Sales, etc. - Provide Personal Questionnaires) Dollar(s) Amount Type of Investment ( Accounts, Loans, Gifts, Asset Sales, etc.) Source of Funds (Identify by Name - Lender, Giftor, Asset Sales, etc. - Provide Personal Questionnaires) Dollar(s) Amount Type of Investment ( Accounts, Loans, Gifts, Asset Sales, etc.) Source of Funds (Identify by Name - Lender, Giftor, Asset Sales, etc. - Provide Personal Questionnaires) Page 8 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original Amended 51 Date 500 FOOT RULE STATEMENT Applicants for on premises liquor licenses must complete this section (Not required for on premises beer or wine application) If the location is subject to the 500 foot rule, and no other exception applies, the license cannot be issued unless the State Liquor Authority makes an affirmative finding that it is in the public interest to issue the license. The provisions of Section 64, 64-a, 64-c and 64-d of the ABC Law require the Authority to consult with the municipality or community board prior to granting a license for ANY ON PREMISES LIQUOR ESTABLISHMENTS where such premises is located within 500' of three or more similarly licensed premises. The Authority is further required to conduct a public hearing, upon notice to the applicant and the municipality or the community board. The proposed premises: Check the appropriate box below: PREMISES IS NOT WITHIN A 500' RADIUS OF THREE OR MORE ESTABLISHMENTS HOLDING ON PREMISES LIQUOR LICENSES. PREMISES IS WITHIN A 500' RADIUS OF THREE OR MORE ESTABLISHMENTS SELLING LIQUOR FOR ON PREMISES CONSUMPTION. IF SO, YOU MUST COMPLETE THE WRITTEN STATEMENT BELOW AND SUBMIT THE NAMES AND ADDRESSES OF THE ESTABLISHMENTS WITHIN THE 500' RADIUS, UNLESS THE PREMISES HAS BEEN CONTINUOUSLY LICENSED ON OR PRIOR TO NOVEMBER 1, 1993. NOT APPLICABLE - PREMISES HAS BEEN CONTINUOUSLY LICENSED ON OR PRIOR TO NOVEMBER 1, 1993 NOT APPLICABLE - POPULATION UNDER 20,000 YOU MUST PROVIDE THE NAMES OF ALL ON PREMISES LIQUOR ESTABLISHMENTS LOCATED WITHIN 500' OF THE PROPOSED PREMISES IMPORTANT: If premises is within a 500' radius of three or more establishments holding on premises liquor licenses and has not been continuously licensed since November 1, 1993 and the population is under 20,000 you must, SUBMIT A WRITTEN STATEMENT EXPLAINING IN DETAIL WHY YOU BELIEVE ISSUANCE OF THE LICENSE WOULD BE IN THE PUBLIC INTEREST. FAILURE TO SUBMIT THIS INFORMATION MAY RESULT IN DISAPPROVAL OF THE LICENSE APPLICATION. Page 9 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original Amended 51 Date STATEMENT OF AREA PLAN THIS QUESTION MUST BE ANSWERED BY ALL APPLICANTS REGARDLESS OF LICENSE TYPE Is the premises within 200' of ANY SCHOOL, CHURCH or PLACE OF WORSHIP? (Exclusive use as a church or place of worship will be determined by this agency) (Please respond "YES" if ANY school, church or place of worship is within 200') YES NO List the name, address and distance from the premises to the CLOSEST SCHOOL, CHURCH, or PLACE OF WORSHIP WITHIN 500 FEET If within 200' submit a BLOCK PLOT DIAGRAM or AREA MAP showing the location of any school, church or place of worship in proximity to your proposed premises ( 8½" x 11") Indicate distance in feet from the proposed premises. Attach additional sheets if necessary. ATTACH A STATEMENT INDICATING HOW THESE MEASUREMENTS WERE TAKEN 1. Name of church/school: Address: Distance: 2. Name of church/school: Address: Distance: 3. Name of church/school: Address: Distance: 4. Name of church/school: Address: Distance: If applying for a full liquor license (beer, wine and liquor) and the premises is within 200' of a school, church or place of worship, the application may be denied. If any discrepancy in the measurements is brought to the attention of the Authority during the examination of the application, it may be necessary for the applicant to supply a certified survey showing the actual measurement from the premises to the closest school, church or place of worship. Page 10 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Amended Original 56 Date ESTABLISHMENT QUESTIONNAIRE 1. Describe the area where the premises is to be located: Residential Business Shopping Mall 1a. State what the area is zoned for: (ie. Residential, Business, Mixed) 2. Premises a. Describe the type of building in which the premises will be located and list the number of floors in the building. ( Example: single unit, multi unit, shopping mall, etc. ) b. Has the building/premises been known by any other address? YES NO If YES. please specify: c. Has the premises to be licensed and/or any other floor in the building been previously licensed or currently licensed for the sale of alcoholic beverages? YES NO d. What was prior use of premises to be licensed? e. Any outside area or sidewalk café used for the sale or consumption YES NO of alcoholic beverages? (such as roof, yard, deck) If YES: 2. Is a permit required by locality for outside area? NO YES 1. Describe in box below and show on diagram. 3. Explain how area is contained (use box below or a separate sheet). continued on next page Page 11 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original Amended 56 Date f. If applying for an on premises license does the premises have a VALID CERTIFICATE OF OCCUPANCY and ALL appropriate permits? YES NO SUBMIT A COPY OF THE CERTIFICATE OF OCCUPANCY OR A LETTER FROM MUNICIPALITY STATING NONE IS NEEDED. g. Are the premises to be licensed divided in any way, by a public or private passageway, etc., over which the applicant does not have exclusive possession and control? YES NO If YES, describe: 3. Premises (interior) Helpful Hint: Drawing your diagram first may assist you in completing the remainder of this section. a. On what floor(s) are the premises located? How many room(s) on each floor? b. Use of room(s)? c. If more than one floor, what is the access between floors (i.e. stairs)? d. If more than one floor, is there interior access to the other floors including the basement? e. How many public bathrooms? g. YES NO f. Location of public bathrooms (include in diagram) What is the maximum number of persons that can legally occupy the premises to be licensed pursuant to the current Certificate of Occupancy or Maximum Occupancy Certificate? What is the maximum number of persons you anticipate occupying the premises to be licensed? h. Number of tables? i. Number of seats at tables? j. Is the interior view unobstructed throughout? YES NO If NO, state reason: k. Any openings to other parts of the building? YES NO If YES, describe: continued on next page Page 12 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Amended Original 56 Date 4. BARS: b. How many service bars*? (Service bar is for wait staff exclusively.) a. How many stand-up bars* are located on the premises? (*Stand-up bar is a bar where cash is exchanged.) c. Describe all bars (length, shape, and location) d. Any food counters? (Do not include bar if listed above) YES NO If YES, describe: * See instructions for definition of stand-up and service bars 5. KITCHEN a. Does premises have a kitchen? YES NO If NO, does premises have a food preparation area? YES NO If any, show on diagram. b. Is food available for sale? YES NO If YES, describe type of food and SUBMIT A MENU c. Is a chef employed at the premises? YES NO If YES, list hours of day chef will devote to the premises: 6. HOTEL a. Type of Hotel: b. How many floors? Transient Apartment Summer c. How many rooms? d. Is there a restaurant in the building(s) housing the proposed hotel? YES NO Page 13 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY 44 Date Amended Original METHOD OF OPERATION 1. Select the type of establishment you are applying for from the list below (based upon your intended method of operation): Bar/Tavern Bed & Breakfast Club (i.e. Golf Club, Fraternal Organization) Catering Establishment Cabaret Hotel Night Club Restaurant Mixed Use (i.e. Restaurant/Night Club, Restaurant/Bar- List the percentage of time the establishment will be operated under each use 2. Will any other business of any kind be conducted in said premises? YES NO (If YES, provide details on a separate sheet) 3. Will premises have music? YES 3a. If yes: NO LIVE RECORDED What type of music? Explain in detail: List the hours each day premises will have music in the boxes below: Sunday From: To: Monday From: To: Tuesday From: To: Wednesday From: To: Thursday From: To: Friday To: Saturday From: 4. Will the premises permit dancing? YES From: To: NO 4a. If YES, describe: 4b. If YES, and are located in NYC, do you have a Cabaret permit issued by the City of New York ? YES NO PENDING continued on next page Page 14 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY 44 Date Amended Original 5. List the proposed hours of operation on the days the premises will be open: Sunday From: To: Monday From: To: Tuesday From: To: Wednesday From: To: Thursday From: To: Friday To: Saturday From: From: To: 5a. If applicable, list hours food will be available for sale. (Attach copy of menu) From: To: 6. Will the business employ a manager? YES NO If YES, see question 6a. 6a. Name(s) of manager(s): (Manager(s) MUST complete a personal questionnaire and submit photo identification prior to employment) 6b. If NO, will principal(s) manage? YES NO 7. How many employees? 7a. If answer is "0" provide explanation. 8. Will there be security personnel? YES NO 8a. If YES, how many? 8b. If they are required to be registered, are they registered in accordance with YES NO New York State Security Guard Registration ? If NO, explain: (ie. Not Required) Security personnel you hire may be required to be registered in accordance with NYS Security Guard Registration. Please contact the NYS Department of State to obtain information. Page 15 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original Amended 6 Date NOTICE OF PUBLICATION Effective August 22, 1999, all applicants for licenses for on premises consumption must publish a NOTICE in a newspaper, designated by the County Clerk, once a week for two successive weeks as hereinafter provided. → If the proposed premises are located in any county other than New York, Kings, Queens, or Bronx, the NOTICE shall be published in a daily OR weekly newspaper in the county where the premises are located. → If the proposed premises are located in the counties of New York, Kings, Queens or Bronx, the NOTICE shall be published in one daily AND one weekly newspaper published in the county where the premises are located. The NOTICE shall be printed in English in substantially the following form: Notice is hereby given that a license, number (fill in serial number) for (fill in beer, liquor and/or wine, as the case may be) has been applied for by the undersigned* to sell (fill in beer, liquor and/or wine, as the case may be) at retail in a (hotel, club, restaurant, vessel, railcar, or other type of establishment, as the case may be) under the Alcoholic Beverage Control Law at (fill in street address, city, town or village and county in which the premises are located) for on premises consumption. (*Applicant's name and Trade Name of business (DBA) must appear at the bottom of the advertisement) The first publication shall be made within 10 days of the filing of the application. Applicant shall obtain two original copies of proof of publication. One original copy must be submitted to the Authority within 15 days of receipt. The second original shall be retained by applicant. Except for good cause shown, the Authority shall not issue the license unless proof of publication is submitted within such 15 day period. The form of proof of publication shall be as follows: STATE OF NEW YORK COUNTY OF ______________________________________ _____________________of____________________ being duly sworn, says that (s)he is _____________________of the publishers of the_____________________ , a (daily) or (weekly) newspaper (printed and) published in the (city, town, or village and county) _____________________, and that the notice of which the annexed is a true copy, has been published in said newspaper for once a week for two successive weeks commencing on the __________day of ______________________________ . Sworn to before me this _______________day of_______________ _______________________________________________________ Page 16 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original Amended 42 Date PROOF OF CITIZENSHIP AFFIRMATION Applicants may submit, in lieu of proof of citizenship, a signed and dated copy of a naturalization certificate or green card with an affirmation on the copy submitted as follows: NOTE: This affirmation can only be submitted by an Attorney duly admitted to practice in the State of New York. All other representatives must present original proof(s) to be verified by the Authority personnel. Applicant/Individual Name: I, the undersigned, an Attorney at Law duly admitted to practice in the State of New York, have compared the original with this copy of: VISA ALIEN REGISTRATION CARD OTHER and affirm under the penalty of perjury that the foregoing copy is a true and complete copy of the original proof of citizenship. This affirmation is given to the Division of Alcoholic Beverage Control knowing that they will rely upon the same in review of the license application of: , and the applicant has signed his name directly in the space provided below. Signature of Applicant Date: Attorney must complete the following signature form: ATTORNEY INFORMATION: Attorney name: Office address: City, Town or Village: Telephone: Signature: State: Zip code: E-mail address: Date: Page 17 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original Amended 137 Date APPLICANT'S STATEMENT I, [print name] corporate principal or LLC/LLP member ) sole proprietor , partner , understand that the State Liquor Authority will rely on each and every answer in the application and ( the accompanying documents in reaching its determination and state, under penalty of perjury, that all statements and representations therein are true to the best of my knowledge and belief; and I state that the location and description of the premises to be licensed does not violate any requirement of the ABC law or other state or local ordinances; and I understand that if any change occurs in the information provided to the Authority in the application, the licensee must notify the Authority by certified mail within 48 hours and if any change occurs after receipt of the license, the licensee must notify the Authority by certified mail within 10 days. I understand that failure to give such notice may result in disapproval of the application or revocation or non-renewal of any license for which this application is submitted; and I understand that the licensee will be bound by the statements and representations made in the application, including, but not limited to the licensee's method of operation and the identity of persons with an ownership or financial interest in the licensed premises; and that all statements and representations made become conditions of the license; and I understand that any physical alterations to, or changes to the size of the area used for the sale and consumption of alcoholic beverages, must be reported to the Authority and may require the approval of the Authority; and I understand that the licensee must keep the Authority advised of any change in the mailing addresses of the licensee, the licensee's principals, and the licensee's landlord. I understand that the licensee's failure to operate the licensed premises in accordance with the statements and representations made in the application may result in revocation of any license for which the application was submitted; and I understand that any false statement or misrepresentation will constitute cause for disapproval of the application or revocation or non-renewal of any license for which this application is submitted. Signature Date Page 18 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original Amended 33 Date APPLICATION FOR LIQUIDATOR'S PERMIT This application is to be completed by the licensee who is selling or liquidating their business and who proposes to dispose of the stock of alcoholic beverages in connection with such sale. This application must be accompanied by a SEPARATE check made payable to the State Liquor Authority for a total fee of $36.00 for each permit. This permit is valid for one transaction only, and requires the sale of the entire stock of alcoholic beverages by the permittee. When the sale is approved, an inventory, signed by the Permittee, listing the type, brand name and size and number of the containers of alcoholic beverages to be sold, must be submitted to the State Liquor Authority. SELLER’S INFORMATION Sellers name: Trade name: Premises address: City, town or village: Zip Code: Telephone number: E-mail address: License serial number: County: License Status: Liquidation of business ONLY, provide date of sale: BUYER'S INFORMATION Buyer's name: Trade name: Premises address: City, town or village: Telephone number: Zip Code: County: E-mail address: The applicant hereby represents that if a permit is issued, the following conditions must be complied with: 1. The alcoholic beverages will be sold and delivered only to manufacturers, wholesalers and retailers duly licensed by the State Liquor Authority. 2. The duplicate permit or photocopy will be delivered to each purchaser. 3. The permittee will pay all excise taxes imposed by or under provisions of Article 18 of the Tax Law and will comply with the rules and regulations of the State Tax Commission. 4. License must be surrendered or placed in safekeeping before permit can be issued. ATTACH ADDITIONAL SHEETS LISTING ALL OF THE INFORMATION REQUESTED ABOVE IF THERE WILL BE MORE THAN ONE LICENSEE PURCHASING YOUR INVENTORY AS PART OF THIS TRANSACTION. THE FOLLOWING CERTIFICATION MUST BE SIGNED AND DATED BY BOTH PARTIES. THE PARTIES SWEAR THAT THE ANSWERS AND STATEMENTS MADE HEREIN ARE TRUE TO THEIR OWN KNOWLEDGE. Seller's Signature: Date: Buyer's Signature: Date: Permits No. Page 19 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Amended Original 14 Date PERSONAL QUESTIONNAIRE a. All principals to the license application must complete this questionnaire in full. (Lendors, donors, guarantors and managers must also complete this questionnaire.) b. If you are a lender,donor or guarantor you must state your relationship to the applicant. c. Make duplicate blank forms as necessary. d. Answer all questions below. e. Attach additional sheets if more space is needed. NAME OF APPLICANT 1. STATEMENT OF IDENTIFICATION Print YOUR name: Date of birth Social Security Number Residence street address City County State Zip Code Residence Telephone U.S. Citizen E-mail Address YES If ALIEN, registration number or VISA type Cellular Phone If NOT U.S. citizen - country of citizenship NO List any other names that you may have been known by (including maiden name) HEIGHT HAIR COLOR MARITAL STATUS WEIGHT EYE COLOR SPOUSE NAME SEX MALE FEMALE SPOUSE'S SOCIAL SECURITY #: 2. Residences for the past TEN years. Address From (month/year) To (month/year) Address From (month/year) To (month/year) Address From (month/year) To (month/year) Address From (month/year) To (month/year) Address From (month/year) To (month/year) continued on next page Page 20 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original Amended 14 Date 3. Your occupation for the past TEN years From/To (month/year) Employer Employer Address Type of business Position From/To (month/year) Employer Employer Address Type of business Position From/To (month/year) Employer Employer Address Type of business Position From/To (month/year) Employer Employer Address Type of business Position 4. Position (or interest) you will hold (check each): President Director Manager Vice President Stockholder Lender* Secretary Partner Donor* Treasurer General Partner Guarantor* Chairman Limited Partner LLC Manager Officer Sole Proprietor LLC Member Other *If Lendor, Donor or Guarantor state your relationship to the applicant. 5. LICENSE HISTORY / AFFILIATIONS If you are an applicant (i.e. proprietor, partner, stockholder, officer or director) or applicant's spouse, will you continue your present occupation or business? YES NO List hours you will devote to business sought to be licensed: continued on next page Page 21 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original Amended 14 Date Will you take an active part in the operation of the business to be licensed? YES NO If YES, explain nature of activity (hours, days, responsibilities): Do you have any interest, direct or indirect, in any premises currently licensed by the Liquor Authority or business where any alcoholic beverage is manufactured, transported or sold at wholesale or retail whether by stock ownership, interlocking directors, mortgage or lien on, or ownership of any real or personal property, or by any other means including loans? YES NO If YES, provide information below: Business name Business address Type of interest and date interest began Serial Number Business name Business address Type of interest and date interest began Serial Number Business name Business address Type of interest and date interest began Serial Number Other than as itemized in the above, have you ever applied in New York State or anywhere for a license or permit to traffic in alcoholic beverages, including any application as a partnership or corporation in which you are/were a principal? YES NO If YES, provide information below: Name of applicant Address of premises Serial Number Disposition Name of applicant Address of premises Serial Number Disposition continued on next page Date of filing Date of filing Page 22 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original Amended Name of applicant Address of premises Serial Number Disposition Name of applicant Address of premises Serial Number 14 Date Disposition Has a license or permit listed above been REVOKED, CANCELED or otherwise Involuntarily Terminated? Date of filing Date of filing YES NO If YES, state action and date of action, and give details: Are you a police commissioner or law enforcement/police officer? YES NO If YES, provide details Page 23 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original Amended 14 Date 6. CONVICTION RECORD AND PENDING CRIMINAL CASES (a) Have you or your spouse (or any officer, director, shareholder or partner listed in this application or the spouse of such person) been convicted of a crime addressed by the provisions of Section 126 of the ABC Law (see instructions for statutory disqualification) which would forbid a person to traffic in alcoholic beverages? YES NO If YES, supply details (b) Have you or your spouse (or any officer, director, shareholder or partner listed in this application or the spouse of such person) ever been CONVICTED (including pleas of guilty or suspended sentences) of any felony, misdemeanor (including driving while intoxicated or impaired) or any other type of offense EXCEPT MINOR TRAFFIC INFRACTIONS? YES NO If YES, attach a Certificate of Disposition by the court clerk for each case. If convicted of a felony, submit a Certificate of Relief from Disabilities, if available. Submit an Affidavit explaining all details. (c) If you have previously been approved for a license were all convictions reported to the Authority? (d) Are there any ARRESTS, INDICTMENTS or SUMMONSES PENDING against you or your spouse (or any officer, director, shareholder or partner listed in this application or the spouse of such person) - including driving while intoxicated or impaired? YES NO YES NO (e) IF YES, PROVIDE COPY OF ACCUSATORY INSTRUMENT. 7. INFORMATION CONCERNING AVAILABILITY OF PREMISES Explain how you became aware of the availability of the proposed premises. continued on next page Page 24 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Amended Original 14 Date 8. FINANCES IMPORTANT: Submit any and all records, documents and affidavits that you feel may assist you in explaining the source of monies you will provide for this venture as per instruction sheet. State TOTAL AMOUNT OF MONEY you are providing for this venture: BREAKDOWN OF NATURE OF INVESTMENT: Type of investment (Investment Loan, Contract Debt) Type of investment Dollar ($) Amount Source of Funds (Accounts, Loans, Gifts, Asset Sales, etc.) (enter identification number for accounts) Type of investment (Investment Loan, Contract Debt) Type of investment Dollar ($) Amount Source of Funds (Accounts, Loans, Gifts, Asset Sales, etc.) (enter identification number for accounts) Type of investment (Investment Loan, Contract Debt) Type of investment Dollar ($) Amount Source of Funds (Accounts, Loans, Gifts, Asset Sales, etc.) (enter identification number for accounts) Type of investment (Investment Loan, Contract Debt) Type of investment Dollar ($) Amount Source of Funds (Accounts, Loans, Gifts, Asset Sales, etc.) (enter identification number for accounts) If you are guaranteed a loan with a co-signer or putting up something of value as collateral please complete the following. Identify Co-Signer or Collateral Identify Co-Signer or Collateral Identify Loan/Describe Collateral Identify Co-Signer or Collateral Identify Loan/Describe Collateral Identify Co-Signer or Collateral Signature: Identify Loan/Describe Collateral Identify Loan/Describe Collateral Date: Page 25 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original Amended Date 500 Foot Rule Investigation Waiver Serial Number: Name of Applicant: Trade Name: Premises Address: Premises City: Premises State: Premises Zipcode: I, , applicant, attorney or representative for the (Name of applicant, attorney or representative - printed) above applicant, state as follows: This is an application for a license under the following Section of the ABC Law (initial appropriate section): Section 64 (restaurant/hotel/catering establishment) and it is within 500 feet of three of more existing establishments licensed under Section 64; Section 64-a (bar, tavern, nightclub, adult entertainment establishment) and it is within 500 feet of three of more existing establishments licensed under Section 64-a; Section 64-c (restaurant brewer) and it is within 500 feet of three of more existing establishments licensed under Sections 64, 64-a or 64-c; Section 64-d (cabaret) and it is within 500 feet of an existing establishment licensed under Section 64-d; Section 64-d (cabaret) and it is within 500 feet of three or more existing establishments licensed under Section 64 or 64-c; The applicant understands that, in lieu of conducting its own investigation into the number and types of establishments within 500 feet of the applicant's location, the Authority will rely on the statements made herein and the applicant hereby waives any objection to the Authority's determination that this application is subject to the “500 foot rule”. Signature: Date: Page 26 American LegalNet, Inc. www.FormsWorkFlow.com