OFFICE USE ONLY Amended Original 29 Date APPLICATION FOR ALCOHOLIC BEVERAGE CONTROL RETAIL LICENSE (ON PREMISES BEER and/or WINE) 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): 3. For SEASONAL licenses only - beginning and ending months: 4. LICENSE TYPE: 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: SERIAL #: continued on next page Page 1 of 24 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 SOLE PROPRIETOR 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 in 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 of 24 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 or % of ownership Date of Birth Name of Principal Residence Citizenship Title No. of Shares or % of ownership Date of Birth Name of Principal Residence Citizenship Title No. of Shares or % of ownership Date of Birth Name of Principal Residence Citizenship Title No. of Shares or % of ownership Date of Birth Name of Principal Residence Citizenship Title No. of Shares or % of ownership Date of Birth Name of Principal Residence Citizenship Title No. of Shares or % of ownership Date of Birth Statutory Disqualification: Identify and explain as described in instructions Page 3 of 24 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original Amended 174 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 NO b. Name of current/previous licensee, if known: Do Not Know License Serial Number, if known: 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. continued on next page Page 4 of 24 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Amended Original 174 Date 2. Continued 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 Name Address Nature of interest Date Acquired 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) any 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 License Number License Number Nature of interest Address License Number Nature of interest Page 5 of 24 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 license 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 of 24 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, Page IV, Section B 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 that you feel may assist you in explaining the source of monies as per instruction sheet. List bank accounts numbers from which "total cash" will derive. continued on next page Page 7 of 24 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 of 24 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original Amended 51 Date STATEMENT OF AREA PLAN 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 regardless of the distance in the area below 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 discrepency 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 9 of 24 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: 2. Premises a. Describe the type of building and list the number of floors where premises is to be located. ( 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: 1. Describe below and show on diagram. 2. Is a permit required by locality for outside area? YES 3. Explain how area is contained (use box below or separate sheets) 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: continued on next page Page 10 of 24 American LegalNet, Inc. www.FormsWorkFlow.com NO OFFICE USE ONLY Original Amended 56 Date 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. Will the basement or any other floor be used for storage? If YES, is there interior access to the floor? YES YES NO NO List floors and means of access to each floor. (ie: stairs, elevator, etc. - must be shown on diagram) d. Is there public access to any other floor? YES NO If YES, list floors and means of access to each floor. (ie: stairs, elevator, etc. - must be shown on diagram) e. How many public bathrooms? g. 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? 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 11 of 24 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Amended Original 56 Date 4. BARS: a. How many stand-up bars* are located on the premises? b. How many service bars*? 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? If any, show on diagram. b. FOOD MUST BE AVAILABLE FOR SALE DURING ALL HOURS OF OPERATION Describe type of food and SUBMIT A MENU c. Is a chef employed at the premises? YES NO 6. HOTEL a. Type of Hotel: Transient Apartment Summer b. Is there a restaurant in the building(s) housing the proposed hotel? c. How many floors? YES NO d. How many rooms? Page 12 of 24 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Amended Original 44 Date METHOD OF OPERATION 1. Select the type of establishment you are applying for from the list below (based upon your intended method of operation): Restaurant (Beer and Wine only) Other (Explain) 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? NO YES 3a. Will the premises permit dancing? 3a. If yes: YES NO LIVE RECORDED 3b. If YES, and are located in NYC, do you have a Cabaret permit issued by the City of New York ? YES NO PENDING 4. Select the method of operation that best describes the business: Dance Club Sports Bar Adult Entertainment Pizzeria Cafe Other (Explain) 5. Will the business employ a manager? YES NO YES Wine Bar NO If YES, see question 5a. 5a. Name(s) of manager(s): (Manager(s) MUST complete a personal questionnaire prior to employment) If NO, will principal(s) manage? continued on next page Page 13 of 24 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Amended Original 44 Date 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: 6. How many employees? If answer is "0" provide explanation. 7. Will there be security personnel? YES NO 7b. If YES, how many? (If they are required, are they registered in accordance with New York State Security Guard Registration or are they not required to be registered?) 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. 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 14 of 24 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 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 15 of 24 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 County City State Zip Code U.S. Citizen Email Address YES If ALIEN, registration number or VISA type Residence Telephone 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 16 of 24 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 *If Lendor, Donor or Guarantor state your relationship to the applicant. Other 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 17 of 24 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, day, week): 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 Date interest began Liquor License Number Business name Business address Date interest began Liquor License Number Business name Business address Date interest began Liquor License 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 License Number Disposition Name of applicant Address of premises License Number Date of filing Address of premises Disposition continued on next page Date of filing Page 18 of 24 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original Amended Name of applicant Address of premises License Number Disposition Name of applicant Address of premises License Number 14 Date Date of filing Disposition Date of filing Has a license or permit listed above been REVOKED, CANCELED or otherwise Involuntarily Terminated? 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 19 of 24 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? (c) If YES, attach a Certificate of Disposition by the court clerk for each case and a Certificate of Relief from Disabilities if available and submit an Affidavit explaining all details. If you have reported all convictions to this Authority and were subsequently approved for a license, check here: (d) Are there any ARRESTS, INDICTMENTS or SUMMONSES other than minor traffic infractions 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 Approved: 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 20 of 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: 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 Loan/Describe Collateral Identify Co-Signer or Collateral Identify Loan/Describe Collateral Identify Co-Signer or Collateral Identify Loan/Describe Collateral Identify Co-Signer or Collateral Identify Loan/Describe Collateral Signature: Date: Page 21 of 24 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 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 Attorney must complete the following signature form: ATTORNEY INFORMATION: Attorney name: Office address: City, Town or Village: Telephone: State: Zip code: E-mail address: Signature: Date: Page 22 of 24 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Amended Original 137 Date APPLICANT'S STATEMENT I, [print name] corporate principal or LLC/LLP member ) sole proprietor , 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 23 of 24 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original Amended 33 Date APPLICANTION 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 Seller’s 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 24 of 24 American LegalNet, Inc. www.FormsWorkFlow.com