opla-rev08/17/2012 LICENSE OFFICE USE ONLY Original Amended Date 29 APPLICATION FOR ALCOHOLIC BEVERAGE CONTROL RETAIL LICENSE (ON PREMISES) 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: , NY Zip Code: City: 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 other 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): YES Is this application filed under the Self Certification Program? NO 3. For SEASONAL licenses only - beginning and ending months: 4. LICENSE TYPE: (see schedule of fees) CODE: 5. Number of ADDITIONAL BARS (if any): (see instructions) 6. TOTAL PAYMENT DUE: 7. Federal Tax ID #: 7a. Certificate of Authority Permit#: 8. Are there any local option restrictions in this area (DRY, PARTIALLY DRY)? YES NO If YES, explain: DO NOT KNOW THE COMMUNITY BOARD/MUNICIPALITY NOTICE FORM AND PROOF OF MAILING MUST BE SUBMITTED WITH THIS APPLICATION. [OFFICE USE ONLY] continued on next page DATE FILED: SERIAL #: Page 1 American LegalNet, Inc. www.FormsWorkFlow.com opla-rev08/17/2012 29 OFFICE USE ONLY Amended Original Date 9. 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 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 10. 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 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 No. of Shares if Corporation or % of ownership if LLC or Partnership Name of Principal Title 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 No. of Shares if Corporation or % of ownership if LLC or Partnership Date of Birth 10a. 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 opla-rev08/17/2012 174 OFFICE USE ONLY Amended Original 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, 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 opla-rev08/17/2012 48 OFFICE USE ONLY Original Amended Date LANDLORD IDENTIFICATION INFORMATION 1. Name of Landlord (as appears on lease and deed): 2. Landlord Mailing Address Street Address: City: State: Zip Code: 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). 6(a). NO If YES, list the names and serial numbers: Are any persons listed on this form police officers: 6(b). YES YES NO If YES, list the names : 7. List number of years real property has been owned by landlord: Page 4 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY opla-rev08/17/2012 Amended Original 28 Date LIST OF EXPENSES FOR THIS VENTURE Expense Item (Actual or Estimated) 1. Real Property (if purchased within the past year): 2. Purchase/Contract Price of Business (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, etc.) Source of Funds (Identify by Name - Lender, etc. - Provide Personal Questionnaires) Dollar(s) Amount Type of Investment ( Accounts, Loans, etc.) Source of Funds (Identify by Name - Lender, etc. - Provide Personal Questionnaires) Dollar(s) Amount Type of Investment ( Accounts, Loans, etc.) Source of Funds (Identify by Name - Lender, etc. - Provide Personal Questionnaires) Dollar(s) Amount Type of Investment ( Accounts, Loans, etc.) Source of Funds (Identify by Name - Lender, etc. - Provide Personal Questionnaires) continued on next page Page 5 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY opla-rev08/17/2012 Original Amended 28 Date List bank names and account numbers from which "TOTAL CASH" will derive. Dollar(s) Amount Type of Investment ( Accounts, Gifts, Asset Sales, etc.) Source of Funds (Identify by Name - Giftor, Asset Sales, etc. - Provide Personal Questionnaires) Dollar(s) Amount Type of Investment ( Accounts, Gifts, Asset Sales, etc.) Source of Funds (Identify by Name - Giftor, Asset Sales, etc. - Provide Personal Questionnaires) Dollar(s) Amount Type of Investment ( Accounts, Gifts, Asset Sales, etc.) Source of Funds (Identify by Name - Giftor, Asset Sales, etc. - Provide Personal Questionnaires) Dollar(s) Amount Type of Investment ( Accounts, Gifts, Asset Sales, etc.) Source of Funds (Identify by Name - 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 SEE INSTRUCTIONS FOR A LIST OF ALL PERSONS REQUIRING PERSONAL QUESTIONNAIRES Page 6 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY opla-rev08/17/2012 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 over 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 7 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY opla-rev08/17/2012 Original Amended 51 Date 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 8 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY opla-rev08/17/2012 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. ( 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 9 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY opla-rev08/17/2012 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. 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: 1. Does any other person/entity have access to this area? YES NO 2. Which floor(s)? 3. 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. How many public bathrooms? If less than two (2) public bathrooms you must request a waiver of the two(2) bathroom rule in writing. f. Location of public bathrooms (include in diagram) g. 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? h. Number of tables? i. Number of seats at tables? continued on next page Page 10 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY opla-rev08/17/2012 Original 56 Date Amended j. Is the interior view unobstructed throughout? YES NO YES NO If NO, state reason: k. Any openings to other parts of the building? If YES, describe: 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. FOOD MUST BE AVAILABLE FOR SALE DURING ALL HOURS OF OPERATION b. Is a chef employed at the premises? YES SUBMIT A MENU NO If YES, list hours of day chef will devote to the premises: 6. HOTEL a. How many floors? b. How many rooms? c. Is there a restaurant in the building(s) housing the proposed hotel? YES NO 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 11 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY opla-rev08/17/2012 Amended Original 44 Date METHOD OF OPERATION FOR ON-PREMISES LIQUOR APPLICANTS 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 (Fraternal Organization - Members Only) Catering Establishment Cabaret Hotel Night Club Restaurant FOR ON-PREMISES BEER OR BEER AND WINE APPLICANTS 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? YES 4. Will the premises permit dancing? NO 3a. If yes: YES LIVE RECORDED NO 4a. If YES, and are located in NYC, do you have a Cabaret permit issued by the City of New York ? YES NO PENDING 5. Select the method of operation that best describes the business: Restaurant Dance Club Pizzeria Cafe 6. Will the business employ a manager? Sports Bar Adult Entertainment Wine Bar Other (Explain) 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 continued on next page Page 12 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY opla-rev08/17/2012 Original Amended 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: 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. 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 13 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY opla-rev08/17/2012 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 14 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY opla-rev08/17/2012 Original 42 Date 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 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: Attorney ID # Office address: City, Town or Village: Telephone: Signature: State: Zip code: E-mail address: Date: Page 15 American LegalNet, Inc. www.FormsWorkFlow.com opla-rev08/17/2012 137 OFFICE USE ONLY Original Amended 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 16 American LegalNet, Inc. www.FormsWorkFlow.com opla-rev08/17/2012 33 OFFICE USE ONLY Original Date 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 17 American LegalNet, Inc. www.FormsWorkFlow.com opla-rev08/17/2012 14 OFFICE USE ONLY Amended Original 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 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 18 American LegalNet, Inc. www.FormsWorkFlow.com opla-rev08/17/2012 14 OFFICE USE ONLY Original Amended Date 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 19 American LegalNet, Inc. www.FormsWorkFlow.com opla-rev08/17/2012 14 OFFICE USE ONLY Amended Original Date 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 20 American LegalNet, Inc. www.FormsWorkFlow.com opla-rev08/17/2012 14 OFFICE USE ONLY Original Amended Date 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 21 American LegalNet, Inc. www.FormsWorkFlow.com opla-rev08/17/2012 14 OFFICE USE ONLY Original Amended Date 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 22 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY opla-rev08/17/2012 Amended Original -136 Date 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, Check FEE or SALARY 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 23 American LegalNet, Inc. www.FormsWorkFlow.com