lsws-rev08/17/2012 Original OFFICE USE ONLY Date LICENSE Amended 29 APPLICATION FOR ALCOHOLIC BEVERAGE CONTROL RETAIL LICENSE (LIQUOR or WINE STORE) 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): Mailing Address (if different than above): City: State: Zip Code: E-mail address (if available): 2. CONTACT (if different than applicant) 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): Is this application filed under the Self Certification Program? 3. LICENSE TYPE: YES NO CODE: (see schedule of fees) 4. TOTAL PAYMENT DUE: 5. Federal Tax ID #: 6. Certificate of Authority Permit#: 7. Are there any local option restrictions in this area (DRY, PARTIALLY DRY)? YES NO If YES, explain: continued on next page DO NOT KNOW [OFFICE USE ONLY] DATE FILED: SERIAL #: Page 1 American LegalNet, Inc. www.FormsWorkFlow.com lsws-rev08/17/2012 Original OFFICE USE ONLY Date 29 Amended 8. TO BE FILLED IN ONLY BY SOLE PROPRIETOR OR PARTNERS (attach additional sheets if necessary) Name of Individual / Partner Residence Social Security Date of Birth Name of Individual / Partner Residence Social Security Date of Birth Name of Individual / Partner Residence Social Security Date of Birth Name of Individual / Partner Residence Social Security Date of Birth 8a. TO BE FILLED IN ONLY IF YOU WILL EMPLOY A MANAGER Name of Manager Residence Social Security Date of Birth Name of Manager Residence Social Security Date of Birth 9. TO BE FILLED IN ONLY BY CORPORATION OR LLC/LLP APPLICANTS (attach additional sheets if necessary) List the names and address or Principals (Stockholders, Officers, Directors, LLC Members/Managers, LLP Partners) Name of Principal Title No. of Shares if Corporation or % of ownership if LLC or Partnership Name of Principal Title No. of Shares if Corporation or % of ownership if LLC or Partnership Date of Birth Social Security #: Residence No. of Shares if Corporation or % of ownership if LLC or Partnership Name of Principal Title Date of Birth Social Security #: Residence Name of Principal Title Social Security #: Residence Date of Birth Social Security #: Residence No. of Shares if Corporation or % of ownership if LLC or Partnership Date of Birth 9a. TO BE FILLED IN ONLY IF YOU WILL EMPLOY A MANAGER Name of Manager Residence Social Security Date of Birth Name of Manager Residence Social Security Date of Birth continued on next page Page 2 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Date lsws-rev08/17/2012 174 Amended Original 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, list the section/page of the lease this information can be found 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 anyone other than the applicant/principals 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 Page 3 American LegalNet, Inc. www.FormsWorkFlow.com lsws-rev08/17/2012 OFFICE USE ONLY Date 48 Amended Original LANDLORD IDENTIFICATION INFORMATION 1. Name of Landlord (as appears on lease and deed): Landlord Mailing Address: City: State: Zip Code: Phone Number (include area code): 2. Landlord Principals Name Address Name Address Name Address Name Address 3(a). Are any persons listed on this form currently or previously licensed under the ABC Law? 3(b). If YES, list the names and license numbers: 4(a). Are any persons listed on this form police officers: 4(b). If YES, list the names : YES YES NO NO 5. List number of years real property has been owned by landlord: Page 4 American LegalNet, Inc. www.FormsWorkFlow.com lsws-rev08/17/2012 OFFICE USE ONLY Date 28 Amended Original LIST OF EXPENSES FOR THIS VENTURE ALL APPLICANTS MUST COMPLETE THIS SECTION Expense Item (Actual or Estimated) 1. Real Property (if purchased within the past year): 2. Purchase/Contract price (submit copy of contract): 3. Renovations/Improvement Costs (ie: furnishings, fixtures, etc.) : 4. Miscellaneous (any other expense related to this venture): (See Instructions for required verifications) 5. TOTAL CASH 6. TOTAL DEFERRED (Total deferred includes loans, mortgages, lines of credit, notes, etc. Attach copies of EACH source of deferred monies) 7. TOTAL INVESTMENT NOTE: The amounts in items 1 through 4 must total the amount reflected in item 7. The amounts in items 5 and 6 must total the amount reflected in item 7. 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 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) continued on next page Page 5 American LegalNet, Inc. www.FormsWorkFlow.com lsws-rev08/17/2012 Original OFFICE USE ONLY Date 28 Amended List bank names and account numbers from which "TOTAL CASH" 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) 8. Have all investors been disclosed in this application? YES NO The following person(s) MAY NOT invest in a retail license to traffic in alcoholic beverages: Convicted felons, persons under the age of twenty-one(21), police officers, and anyone with an interest in a wholesale license. You must supply Personal Questionnaires for all investors or joint account holders Page 6 American LegalNet, Inc. www.FormsWorkFlow.com lsws-rev08/17/2012 OFFICE USE ONLY Date 56 Amended Original 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. 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: continued on next page Page 7 American LegalNet, Inc. www.FormsWorkFlow.com lsws-rev08/17/2012 Original OFFICE USE ONLY Date 56 Amended 3. Premises (interior) Helpful Hint: Drawing your diagram first may assist you in completing the remainder of this section. a. List all floors you wish to license? b. Use of room(s)? c. Will the basement or any other floor(s) be used for storage of alcoholic beverages? YES NO If YES: Which floor(s)? Is there interior access to the floor(s)? (If YES, the storage area must be part of the licensed premises. If NO, you must apply for a warehouse permit in order to use this area for storage of alcoholic beverages) YES NO State the means of access to each floor. (ie: stairs, elevator, etc. - must be shown on diagram) d. Is there interior access to any other floor(s) that will not be part of the licensed premises? YES NO If YES, list floor(s)s and means of access to each floor(s). (ie: stairs, elevator, etc. - must be shown on diagram) List use of floor(s). (ie: apartments, offices, etc.) e. What is the square footage of the proposed premises? Section 105(2) of the Alcoholic Beverage Control Law requires that Liquor/Wine Stores have only one(1) public entrance that is located at street level and on a public thoroughfare. There may be one(1) additional public entrance that is located at street level and gives access to and from a public or private parking lot that has space for not less than five(5) automobiles. Please mark the diagram to reflect what each door of the premises is to be used for (ie. emergency exit only, deliveries, public entrance, etc.) Section 100(7) of the Alcoholic Beverage Control Law requires that Notice be posted in a conspicuous place at the entrance of the premises within 10 days of filing your application. This Notice Form can be found on our website under "Notice to be Posted at Proposed Premises". YOU MUST PROVIDE PROOF OF SUCH NOTICE VIA A PHOTOGRAPH OF POSTED NOTICE Page 8 American LegalNet, Inc. www.FormsWorkFlow.com lsws-rev08/17/2012 44 OFFICE USE ONLY Date Amended Original PROPOSED METHOD OF OPERATION 1. Select the type of establishment you are applying for from the list below (based upon your intended method of operation): Liquor Store Wine Store 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 the business employ a manager? YES NO If YES, see question 4a. 3a. Name(s) of manager(s): (Manager(s) MUST complete a personal questionnaire prior to employment) 3b. If NO, will principal(s) manage? YES NO 4. How many employees? 4a. If answer is "0" provide explanation. 4b. NYS Law requires businesses to carry workers' compensation and disability insurance (see instructions). Workers' Compensation Carrier Name and Policy Number: Disability Insurance Carrier Name and Policy Number: ALCOHOLIC BEVERAGES MAY ONLY BE CONSUMED, SOLD OR GIVEN AWAY DURING THE HOURS APPROVED BY THE COUNTY WHERE THE PREMISES IS LOCATED UNLESS FURTHER RESTRICTED BY THE AUTHORITY Page 9 American LegalNet, Inc. www.FormsWorkFlow.com lsws-rev08/17/2012 Original OFFICE USE ONLY Date 51 Amended STATEMENT OF AREA PLAN THIS QUESTION MUST BE ANSWERED BY ALL APPLICANTS REGARDLESS OF LICENSE TYPE 1. List the name, address and distance from the premises to ANY SCHOOL, CHURCH, or PLACE OF WORSHIP WITHIN 300 FEET 2. 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') 3. YES NO 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 lsws-rev08/17/2012 Original OFFICE USE ONLY Date 55 Amended LIQUOR / WINE STORE QUESTIONNAIRE Package/Wine Store applicants for premises NOT currently licensed must complete this section . 1. List the four closest package and/or wine stores and distance from the proposed premises location (IN MILES OR FEET). A. Store Name: Address: Distance: B. Store Name: Address: Distance: C. Store Name: Address: Distance: D. Store Name: Address: Distance: SUBMIT AN AREA MAP (USING 8½” x 11” PAPER) SHOWING PROXIMITY OF THESE STORES TO APPLIED FOR PREMISES. 2. Will applicant engage in internet sale of alcoholic beverages? 2a. YES NO If yes, describe method of operation: Page 11 American LegalNet, Inc. www.FormsWorkFlow.com lsws-rev08/17/2012 Original OFFICE USE ONLY Date 42 Amended 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 affirms 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 ID #: Attorney name: Office address: City, Town or Village: Telephone: Signature: State: Zip code: E-mail address: Date: Page 12 American LegalNet, Inc. www.FormsWorkFlow.com lsws-rev08/17/2012 Original 137 OFFICE USE ONLY Date Amended APPLICANT'S STATEMENT I, [print name] sole proprietor, corporate principal or LLC/LLP member ) partner, of the applicant for an Alcoholic Beverage Control License understand that the State Liquor Authority will ( the rely on each and every answer in the application and 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 13 American LegalNet, Inc. www.FormsWorkFlow.com lsws-rev08/17/2012 Original OFFICE USE ONLY Date 33 Amended 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 14 American LegalNet, Inc. www.FormsWorkFlow.com lsws-rev08/17/2012 OFFICE USE ONLY Date 14 Amended Original 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 County City 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. 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 ABC Officer Other *If Lendor, Donor or Guarantor state your relationship to the applicant. continued on next page Page 15 American LegalNet, Inc. www.FormsWorkFlow.com lsws-rev08/17/2012 Original OFFICE USE ONLY Date 14 Amended Print YOUR Name 3. 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) 4. Your occupation for the past TEN years From/To (month/year) Employer Type of business Employer Address Position From/To (month/year) Employer Type of business Employer Address Position From/To (month/year) Employer Type of business Employer Address Position 5. LICENSE HISTORY / AFFILIATIONS (a) 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 16 American LegalNet, Inc. www.FormsWorkFlow.com lsws-rev08/17/2012 Original OFFICE USE ONLY Date 14 Amended Print YOUR Name (b 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): (c) 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 (d) 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 17 American LegalNet, Inc. www.FormsWorkFlow.com lsws-rev08/17/2012 Original OFFICE USE ONLY Date 14 Amended Print YOUR Name Name of applicant Address of premises Serial Number Disposition Name of applicant Address of premises Serial Number Disposition (e) 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: (f) Are you a police commissioner or law enforcement/police officer? YES NO If YES, provide details Page 18 American LegalNet, Inc. www.FormsWorkFlow.com lsws-rev08/17/2012 Original OFFICE USE ONLY Date 14 Amended Print YOUR Name 6. CONVICTION RECORD AND PENDING CRIMINAL CASES (a) Have you or your spouse ever 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? YOU SPOUSE YES YES NO NO If YES, supply details (b) Have you or your spouse ever been CONVICTED (including pleas of guilty or suspended sentences) of any felony, misdemeanor or driving while intoxicated or impaired? YOU SPOUSE YES YES 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. NO NO (c) YES If you have previously been approved for a license and had been convicted of any felony misdemeanor or other type of offense except minor traffic infractions were all convictions reported to the Authority? 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. (d) Are there any ARRESTS, INDICTMENTS or SUMMONSES PENDING against you or your spouse - including driving while intoxicated or impaired? NO YOU SPOUSE YES NO IF YES, PROVIDE COPY OF ACCUSATORY INSTRUMENT. YES NO 7. Do you have any relationship with the current/previous licensee or any of the principals of the licensee? YES NO If YES, please state exactly what the relationship is (ie: family member) Signature: Date: Page 19 American LegalNet, Inc. www.FormsWorkFlow.com lsws-rev08/17/2012 OFFICE USE ONLY Date -136 Amended Original STATE OF NEW YORK NOTICE OF APPEARANCE Section 166 of the Executive Law requires a regulatory agency to maintain for public inspection, a record of who appears before it, for a fee as a third party (i.e., an attorney, an agent, lobbyist*, or representative) on behalf of a person or organization subject to the regulatory jurisdiction of the agency. This usually occurs when the third party’s client is involved in an enforcement, formal permit, or application matter. This form is subject to all the rules and regulations of the Freedom of Information Law. Information that is confidential as a matter of law need not be furnished. Agency: Date: Division/Bureau: 1. Name of individual appearing: Address: Telephone: 2. Client represented: Address: Telephone: 3. Subject of appearance: Regulatory/Enforcement Lobbying 4. Acting in capacity of: Attorney Lobbyist Agent Other (describe) 5. Are you being compensated? Yes If Yes, Fee: No Salary: 6. Signature of individual appearing: 7. Agency official (print name): Signature: *A LOBBYIST is a person or organization, other than a New York State government employee acting in an official capacity, who appears for the purpose of influencing the adoption or rejection of proposed rules, regulations, rates, legislation, including the State budget or the specification or award of a State Procurement Contract. An "appearance” for lobbying purposes can be a personal visit, letter, telephone call, conversation at a meeting, or any other type of contact, but does not include “on the record” proceedings or hearings. Page 20 American LegalNet, Inc. www.FormsWorkFlow.com