-29 SECTION A NEW YORK STATE LIQUOR AUTHORITY APPLICATION FOR ALCOHOLIC BEVERAGE MANUFACTURER/WHOLESALER LICENSE 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 TRADE NAME (D/B/A) Premises Street Address City, Town or Village ZIP County Tel. No. Between what streets Premises Post Office Address (if different from above) E- mail Address _____________________________________________________________________________________ 2. LANDLORD NAME Landlord Address City, Town or Village ZIP Tel. No. 3. ATTORNEY/REPRESENTATIVE NAME Office Address City, Town or Village ZIP Tel. No. CODE: ___ ___ ___ 4. ALCOHOLIC BEVERAGE LICENSE CLASS: 5. TOTAL PAYMENT DUE ......................................................................................................................................$ __________ 6. PENAL BOND DUE - (See attached fee schedule).................................................................................................$ __________ [OFFICE USE ONLY] DATE FILED: COUNTY CODE # STATE LIQUOR AUTHORITY ACTION: APPROVAL DISAPPROVAL DATE OF ISSUANCE: SERIAL NUMBER: FORM: SLA APP. (REVISED 11/27/07) 8 American LegalNet, Inc. www.FormsWorkflow.com 7. TO BE FILLED IN ONLY BY INDIVIDUAL OR PARTNERSHIP APPLICANTS NAME OF APPLICANT RESIDENCE CITIZENSHIP DOB _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ 8. TO BE FILLED IN ONLY BY LIMITED LIABILITY COMPANY OR LIMITED LIABILITY PARTNERSHIP NAME 9. MEMBER OR MANAGER POSITION % OF OWNERSHIP INTEREST TO BE FILLED IN ONLY BY CORPORATION APPLICANTS (a) State under what law applicant was organized: (b) Date of organization: (c) If applicant is a foreign corporation, has a certificate of authority been obtained to do NO YES _____ business in this state? (d) If YES, date of certificate: (e) Name of principal place of business: (f) Address of principal place of business: (g) Number of outstanding shares: (h) List names and addresses of the STOCKHOLDERS, all OFFICERS and DIRECTORS as of the date of filing of this application: NAME OF STOCKHOLDER/ RESIDENCE CITIZENSHIP TITLE NO. OF SHARES BIRTH DATE OFFICER/DIRECTOR _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ 10(a) Does applicant occupy said premises under a written lease or option to lease? 9 NO YES ______ American LegalNet, Inc. www.FormsWorkflow.com (b) If YES, state name and address of immediate lessor? (c) Date and Duration of lease: (d) Do the terms of the lease or other arrangement require payment by the applicant of any NO YES _____ NO YES ______ NO YES ______ consideration based on a percentage of the receipts of the business? (e) 11.(a) If YES, state percentage and give details: Is any license under the Alcohol Beverage Control Law now in effect for the premises for which this application is filed? (b) If YES, state name of licensee: (c) License number: 12(a) (b) Will any other business of any kind be carried on in said premises? If YES, provide details: 13(a) If applying for a Farm Winery License, is the premises located on a farm? Provide NO_______YES________ a detailed description of the premises and location of the vineyard. (b) If applying for a Farm Distiller License, will the applicant share a tasting room with NO_______YES________ a licensed winery or farm winery? 14. Are the said premises located in a district created under any zoning laws which restricts NO YES ______ NO YES ______ NO YES ______ NO YES ______ NO YES ______ the maintenance of a business at the premises to be licensed? 15. Do said premises comply with all applicable building, fire and health laws, ordinances and regulations? 16(a) Are premises located within 200 feet of a building occupied exclusively as a school, church, synagogue or other place of worship, which is located on the same street or avenue? (b) If YES, state what date said premises have been continuously licensed under the Alcoholic Beverage Control Law? (c) If YES, provide the names and addresses in Section D, Statement of Area Plan, and indicate on the Block Plot Diagram? 17(a) Did you notify the appropriate Community Board or Municipality of your application and submit the original proof of mailing with your application? (b) Does the proposed location of the business comply with all state and local 10 American LegalNet, Inc. www.FormsWorkflow.com regulations and zoning codes? 18(a) NO _______ YES ______ Does any person not an applicant herein, or if a corporate applicant, any person not an officer, director or stockholder of such corporation any interest, financial, proprietary or other, direct or indirect, in the premises or in the business to be licensed or has made any loan to the applicant for said business, or has any lien or mortgage on the fixtures in the business? (b) If so, state the names and addresses of such persons, the nature of their interest and the date when it was acquired? NAME ADDRESS DATE ACQUIRED ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ 19(a) Does any person not an applicant herein, or, if a corporate applicant, any person not an NO YES ______ officer, director or stockholder of such corporation, or any person not reported in questions above, 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. (b) If so, state the names and addresses of such persons, the nature and percent of their share and date acquired. NAME ADDRESS STOCK SHARES DATE ACQUIRED ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ 20(a) Has the applicant or (if a partnership) any of the partners or (if a corporation) any of the NO YES ______ NO YES ______ NO YES ______ officers, directors or stockholders any interest, directly or indirectly, in any 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 of any real or personal property, or by any other means including loans? (b) If YES, state the name and addresses of the premises, the license number, the date the interest was acquired and the exact nature of the interest. __________________________________________________________________ __________________________________________________________________ 21(a) Has the applicant or (if partnership) any of the partners or (if a corporation) any of the officers, directors or stockholders, or any agent or employee of the applicant, ever been CONVICTED (including pleas of guilty or suspended sentences) of any felony or of any other crime or offense of any kind except traffic infractions? (b) If YES, state date of conviction, crime or offense involved and name of person convicted. In each case a CERTIFICATE OF DISPOSITION or a CERTIFICATE OF CONVICTION by the Court Clerk must be attached. CRIME OR OFFENSE DATE 11 NAME OF PERSON CONVICTED American LegalNet, Inc. www.FormsWorkflow.com ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ 22(a) Are there any ARRESTS, INDICTMENTS or SUMMONS (except for traffic NO YES ______ infractions) PENDING against the applicant or (if a partnership) any of the partners or (if a corporation) any of the officers, directors or stockholders, or any agent or employee of the applicant? (b) If YES, state date of conviction, crime or offense involved and name of person convicted. In each case a CERTIFCATE OF DISPOSITION or a CERTIFICATE OF CONVICTION by the Court Clerk must be attached. CRIME OR OFFENSE DATE NAME OF PERSON CONVICTED ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ 23. (b) Federal Taxpayer Identification No.: If you did not provide your Tax Number, indicate the Number applied for reason: and pending __________ Number not required, exempt organization 24. __________ Certificate of Authority to Collect Sales Tax Number: (Applies only to licensees selling at retail directly to consumer; attach copy) 25(a) Are you an employer or corporation with one or more employees? NO YES ______ If YES, complete the following: (b) Worker's Compensation Policy Number: (c) Company: (d) Effective Date: (e) Disability Benefits Number: (f) Company: (g) Effective Date: 12 American LegalNet, Inc. www.FormsWorkflow.com APPLICANTS MUST SUBMIT THE FOLLOWING DOCUMENTS WITH THIS APPLICATION: See INSTRUCTIONS for complete explanations. 24.) Workers Compensation. 25.) Financial Documents. 26.) Fingerprint Cards. 27.) Contracts. 28.) Photographs. 29.) Diagrams. 13 American LegalNet, Inc. www.FormsWorkflow.com SECTION B -28 LIST OF EXPENSES FOR THIS VENTURE ALL APPLICANTS MUST COMPLETE SECTION B. Expense Item (Actual or Estimated): 1. Real Property 2. Fixtures & Equipment 3. Inventory 4. Security Deposit 5. Attorney/Representative Fees 6. Operating Capital 7. Miscellaneous Expenses 8. SLA Fees 9. First Month's Rent and Any Paid to Date 10. Renovations 11. Goodwill 12. Other 13. Total Cash 14. Total Deferred $ (Total Deferred includes loans, mortgages, lines of credit, notes, etc.) $ Explain how deferred: 15. Total Cost $ * NOTE: The amounts in items 1 through 12 must total the amount reflected in item 15. The amounts in items 13 and 14 must total the amount reflected in item 15. 14 American LegalNet, Inc. www.FormsWorkflow.com SECTION C -48 LANDLORD IDENTIFICATION QUESTIONNAIRE LANDLORD MUST COMPLETE THIS SECTION FOR ALL APPLICATIONS 1. Name of Landlord 2. Premises Address (Premises to be licensed) 3. Type of ownership: 4. Landlord Principals: NAME 5(a) (b) 6(a) Individual Proprietorship Partnership Corporation ADDRESS Are any persons listed on this form police officers? NO If YES, list names: YES ______ ___________________________ Are any persons listed on this form currently or NO YES _______ previously licensed under the ABC law? (b) If YES, list names and license numbers: Signature of LANDLORD: Title: IMPORTANT - Signature must be same as signature on original lease--if not; furnish either affidavit in explanation, affix legible corporate seal or submit other proof of signature's authority. 15 American LegalNet, Inc. www.FormsWorkflow.com SECTION D STATE OF NEW YORK LIQUOR AUTHORITY TO: MANUFACTURERS AND WHOLESALERS SUBJECT: (Series 1953) Bulletin #254 December 1, 1953 MINIMUM OFFICE REQUIREMENTS FOR OUT-OF-STATE WHOLESALERS AND LICENSES OPERATING MORE THAN ONE WHOLESALE PREMSIES WITHIN THE STATE OF NEW YORK. Paragraph 4 of Bulletin #79, issued under date of January 30, 1942, is hereby rescinded. This paragraph dealt with the minimum office requirement for out-of-state wholesalers. These requirements are restated herein and amplified in order to include requirements for licensees operating more than one wholesaler premises within this state. New matter is underlined. Wholesale licensees having their principal offices in another state and wholesale licensees operating more than one licensed premise within the state are required to observe the same provisions of the law governing wholesalers as licensees operating one principal office within the state. Inquiries have been received from such licensees as to the proper method of operating the licensed premises in this state, particularly with respect to the books and records which are to be kept. For the information and guidance of wholesale licensees, the liquor authority has laid down the following minimum office requirements. 1. 2. 3. 4. The licensed premises must be physically separated from any other premises. No other business may be conducted on the licensed premises. The premises must be in charge of any employee of the licensee, and open during regular business hours. The books and records must be kept on the licensed premises, which shall show: a. All purchases of alcoholic beverage made within or without the state by the New York licensee, together with the names, addresses and license numbers of the persons from whom the same were purchased. A separate record must be kept of all alcoholic beverages which a branch office receives from the main office which is licensed within the state. b. All sales of alcoholic beverages made within the state, together with the names, addresses and license numbers of purchasers, including invoices and delivery receipts. A separate record must be kept of all shipments of alcoholic beverages made to the main office of the licensee which is licensed within the State of New York. c. The receipt of all payments for alcoholic beverages sold within the state. d. The names and addresses of all employees operating within the state, together with their salaries or commissions and permit numbers. Where the licensee operates more than one premise within the state and where complete records are maintained on a licensed premise within the state and available for inspections, duplicate records of these items are not required to be kept on the premises of the branch office. e. All expenditures for the maintenance or operations of the New York licensed premises or branch office. Where the licensee operates more than one premise within the state and where complete records of expenditures for the maintenance or operation of all branch offices are maintained on a licenses premise within the state and available for inspection duplicate records of these items are not required on the premises of the branch offices. All out-of-state wholesalers who are unable to keep the original records on the licensed premises in this state, must apply to the State Liquor Authority in writing for permission to keep duplicate records in place of the originals. 16 American LegalNet, Inc. www.FormsWorkflow.com SECTION E -1 APPLICANT’S STATEMENT Any answer or statement, which is false, made by the applicant may constitute perjury and may subject any permit or license issued hereunder to revocation or cancellation. I, ____ __________, the applicant, (sole proprietor, partner, corporate principal or LLC/LLP member) for an Alcoholic Beverage Control Wholesale License understand that the New York State Liquor Authority will rely on each and every answer in the application and accompanying papers in reaching their determination and state, under penalty of perjury, that all statements therein are true to the best of my knowledge and belief. I further state that the location and description of the premises to be licensed does not violate any requirement of the ABC Law or local ordinances. I verify if any change occurs prior to the receipt of the license, I will notify the Authority by registered or certified mail within 48 hours or if change occurs after receipt of the license, I will notify the Authority similarly within 10 days. I understand that failure to give the required notice will violate the Alcoholic Beverage Control Law and may result in disapproval of your application, or revocation of the license. Signature Date 17 American LegalNet, Inc. www.FormsWorkflow.com SECTION F -14 PERSONAL QUESTIONNAIRE A. ALL PRINCIPALS TO THE LICENSE APPLICATION MUST COMPLETE THIS QUESTIONNAIRE IN FULL. B. MAKE DUPLICATE BLANK FORMS AS NECESSARY. C. ANSWER ALL QUESTIONS BELOW AND CHECK THE APPROPRIATE SPACES. D. ATTACH ADDITIONAL SHEETS IF MORE SPACE IS NEEDED. 1) APPLICANT NAME Premises Address County 2. YOUR NAME Address Social Security No. Date of Birth Telephone No. 3. List any other name or names you have been known by (including maiden name) and the reason for changing your name: 4. Height 5. U.S. Citizen? Weight Marital Status Sex Hair Color NO YES ______ Country of Birth: If Alien, state Registration No. or Visa Type: 6. Residences for past ten years including your present address: ADDRESS FROM (MO./YR.) TO (MO./YR.) _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ 7.) Your Occupation record for the past ten years: FROM/TO (MO./YR.) EMPLOYER TYPE OF BUSINESS ADDRESS OCCUPATION _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ 8. NAME OF SPOUSE Address 18 American LegalNet, Inc. www.FormsWorkflow.com Social Security No. Telephone No. 9. Position (or interest) you will hold in the license application (Check each): President Management Agent Broker V. President Landlord Vendor Secretary Stockholder Contractor Treasurer Partner Franchisor Chairman General Partner Guarantor Officer Limited Partner Donor Director Sole Proprietor Lender Manager LLC Manager LLC Member OTHER: 10(a) If you are an Applicant (i.e., proprietor, partner, or stockholder, officer or director) or NO YES ______ Applicant's spouse, will you continue your present occupation or business? (b) Not Applicable If Yes, list hours you will devote to business sought to be licensed: ________________________ ________________________ 11(a) Do you have any interest, direct or indirect, in any premises or business where any NO YES ______ 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? (b) If Yes, provide information below: BUSINESS TYPE OF YOUR INTEREST BUSINESS LIQUOR FEDERAL NAME BUSINESS (DATE BEGAN) ADDRESS LICENSE ID NO. _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ 12(a) Other than as itemized in the above, have you ever applied anywhere for a license or NO YES _____ permit to traffic in alcoholic beverages, including any application as a partnership or corporation in which you are/were a principal? 19 American LegalNet, Inc. www.FormsWorkflow.com (b) If YES, provide information below: NAME OF APPLICANT ADDRESS OF PREMISES DATE OF FILING LICENSE# DISPOSITION _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ 13(a) Has a license or permit listed above been REVOKED, CANCELLED or otherwise NO YES _____ INVOLUNTARILY TERMINATED? (b) _______________________________ If YES, state action and date of action: ___________________________ _____________________________ 14(a) Will you take an active part in the operation of the business to be licensed? NO YES ______ If YES, explain nature of activity: _______________________________ (Hours, pay, will you leave your present employment?) (b) ___________________________ _____________________________ 15(a) Are you a police commissioner, other police official, subordinate of any police NO YES _____ department, a Sheriff, Deputy, Under-Sheriff or any Peace Officer? (b) _______________________________ If YES, provide details: ___________________________ _____________________________ 16(a) Have you ever been CONVICTED (including pleas of guilty or suspended sentences) of NO YES ______ any felony, misdemeanor (including driving while intoxicated or impaired) or any other type of offense EXCEPT MINOR TRAFFIC INFRACTIONS? (b) If YES, attach a Certificate of Disposition by the court clerk for each case and a APPROVED 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 -- 17(a) Are there any ARRESTS, INDICTMENTS or SUMMONSES other than minor traffic NO YES ______ NO YES ______ infractions PENDING against you (including driving while intoxicated or impaired)? (b) 18. If YES, provide copy of accusatory instrument. If you are an applicant (i.e. proprietor, partner, or stockholder, officer or director), would any of the above questions require a YES answer if asked of your spouse? 20 NOT an applicant American LegalNet, Inc. www.FormsWorkflow.com 19. If you answered YES to the above question or if your spouse will aid in the Spouse will complete questionnaire; management of the applicant business, check here and your spouse must complete a personal questionnaire. 20. Do you or did you have a family, business or social relationship with the landlord, tenant NO YES ______ or last licensee of the premises to be licensed? 21. FINANCES State TOTAL AMOUNT OF MONEY you are providing the applicant TYPE OF INVESTMENT DOLLAR ($)AMOUNT (Investment/Loan/Contract-debt) $ SOURCE OF FUNDS (Accounts, Loans, Gifts, Asset Sales, Etc.) (enter identification numbers for accounts) _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ IMPORTANT - SUBMIT ANY AND ALL RECORDS, DOCUMENTS AND AFFIDAVITS THAT YOU FEEL MAY ASSIST YOU IN EXPLAINING THE SOURCE OF MONIES YOU WILL PROVIDE THE APPLICANT AS PER INSTRUCTION SHEET. EXAMPLES OF DOCUMENTS TO SUBMIT: A. LOAN OR GIFT LETTER. B. COPY OF BANK OR STOCK ACCOUNT FROM WHICH FUNDS WILL BE LOANED OR GIFTED. FROM THESE ACCOUNTS, COPY OF NAME PAGE AND ALL PAGES GOING BACK ONE YEAR. CIRCLE OR HIGHLIGHT UNUSUAL DEPOSITS AND EXPLAIN. IF FUNDS WERE TRANSFERRED FROM ANOTHER ACCOUNT OR PREVIOUS BANK BOOK(S), COPY OF THE NAME PAGE AND ALL PAGES GOING BACK ONE YEAR FOR THAT BOOK. If you are guaranteeing a loan as a co-signer or putting up something of value as collateral. Identify Co-Signer or Collateral Identify Loan/ Describe Collateral _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ I understand that the information I submit will be relied upon by the State Liquor Authority and a false statement or misrepresentation will constitute cause for the disapproval of the application or revocation of any license for which this application is submitted. 21 American LegalNet, Inc. www.FormsWorkflow.com I verify that statements made herein are true and if any change occurs prior to the receipt of the license, I will notify the Authority by registered or certified mail within 48 hours or if change occurs after receipt of the license, I will notify the Authority similarly within 10 days. I understand that failure to give the required notice will violate the Alcoholic Beverage Control Law and may result in revocation of the license. Signature Date 22 American LegalNet, Inc. www.FormsWorkflow.com SECTION G -42 PROOF OF CITIZENSHIP AFFIRMATION Effective September 4, 1996, in accordance with Divisional Order #807, applicants represented by an attorney may submit, as proof of citizenship, a copy of a naturalization certificate or green card, with a completed copy of the following attorney affirmation. 1. The undersigned, an attorney at law duly admitted to practice in the State of New York, has compared the original with the annexed copy of: PROOF OF CITIZENSHIP Visa Alien Registration Card Other: ___________________________ 2. and affirms under the penalty of perjury that the annexed 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: ATTORNEY INFORMATION Attorney Name: . Office Address: . City, Town or Village: . Zip Code: .Telephone Number: . ATTORNEY AFFIRMATION SIGNATURE/ATTORNEY AT LAW DATE Wholesale appl. Revised (02/2003) 23 American LegalNet, Inc. www.FormsWorkflow.com FILING CHECKLIST You can have the greatest impact on a timely licensing decision by reading the instructions thoroughly and submitting a complete application. After you have completed the application, use this checklist to ensure that you have met all filing requirements. Failure to submit any of the required documents may result in the rejection of your application or processing delays. •Did you complete every question on each required form? •Did you remember to submit the following? 01._____Application 02._____Application Payment Fee 03._____Penal Bond 04._____Fingerprint Cards 05._____Photographs 06._____Personal Questionnaire 07._____Proof of Citizenship 08._____Contract Of Sale and Conveyance 09._____Lease Agreement 10._____Landlord Identification Questionnaire (Section C) 11._____Diagrams 12._____Copies of Bank Statements and Loan Agreements REMEMBER - LICENSES CANNOT BE ISSUED WITHOUT: 13._____Certificate Of Authority to Collect Sales Taxes 14._____Federal Tax Identification Number 15._____Workers Compensation/Disability Benefits Number 16._____Certificate of Occupancy 17._____Copies of Federal Bureau of Alcohol, Tobacco and Firearms permits or an affidavit that you have applied for the permits •Did you sign? 01._____Applicant’s Statement (Section E) 02._____Personal Questionnaire 03._____Fingerprint Card 04._____Personal or Certified Check To the State Liquor Authority 05._____Penal Bond 24 American LegalNet, Inc. www.FormsWorkflow.com