OFFICE USE ONLY Amended Original whlsle-rev090211 Date LICENSE 29 APPLICATION FOR ALCOHOLIC BEVERAGE CONTROL WHOLESALE 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 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): CODE: 3. LICENSE TYPE: (see schedule of fees) 4. TOTAL PAYMENT DUE: 5. Federal Tax ID #: 6. Certificate of Authority Permit# (required only if the license allows for retail privileges): 7. Are there any local option restrictions in this area (DRY, PARTIALLY DRY)? (Answer required only if the license allows for retail privileges) NO DO NOT KNOW If YES, explain: continued on next page YES [OFFICE USE ONLY] DATE FILED: SERIAL #: Page 1 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY whlsle-rev090211 Amended Original Date 29 8. TO BE FILLED IN ONLY BY SOLE PROPRIETOR OR PARTNERS (attach additional sheets if necessary) Name of Individual / Partner Residence Social Security Date of Birth Name of Individual / Partner Residence Social Security Date of Birth Name of Individual / Partner Residence Social Security Date of Birth Name of Individual / Partner Residence Social Security Date of Birth 9. TO BE FILLED IN ONLY BY CORPORATION OR LLC/LLP APPLICANTS (attach additional sheets if necessary) List the names and address or Principals (Stockholders, Officers, Directors, LLC Members/Managers, LLP Partners) Name of Principal Title Residence No. of Shares if Corporation or % of ownership if LLC or Partnership Name of Principal Title Residence No. of Shares if Corporation or % of ownership if LLC or Partnership Name of Principal Title Residence No. of Shares if Corporation or % of ownership if LLC or Partnership Name of Principal Title Residence No. of Shares if Corporation or % of ownership if LLC or Partnership Social Security #: Date of Birth Social Security #: Date of Birth Social Security #: Date of Birth Social Security #: Date of Birth 9a. TO BE FILLED IN ONLY BY CORPORATION OR LLC/LLP APPLICANTS (1) State under what law applicant was organized: (2) Date of organization: (3) If applicant is a foreign corporation, has a Certificate of Authority been obtained to do business in this state? YES NO (3a) If yes, date of Certificate of Authority: (4) Name of principal place of business: (5) Address of principal place of business Page 2 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original whlsle-rev090211 Amended Date 174 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 OFFICE USE ONLY Original whlsle-rev090211 Amended Date 48 LANDLORD IDENTIFICATION INFORMATION 1. Name of Landlord (as appears on lease and deed): Landlord Mailing Address: City: State: Zip Code: Phone Number (include area code): 2. Landlord Principals Name Address Name Address Name Address Name Address 3(a). Are any persons listed on this form currently or previously licensed under the ABC Law? 3(b). If YES, list the names and license numbers: 4(a). Are any persons listed on this form police officers: 4(b). If YES, list the names : YES YES NO NO 5. List number of years real property has been owned by landlord: Page 4 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original whlsle-rev090211 Amended Date 28 LIST OF EXPENSES FOR THIS VENTURE ALL APPLICANTS MUST COMPLETE THIS SECTION Expense Item (Actual or Estimated) 1. Real Property (if purchased within the past year): 2. Purchase/Contract price (submit copy of contract): 3. Renovations/Improvement Costs (ie: furnishings, fixtures, etc.) : 4. Miscellaneous (any other expense related to this venture): (See Instructions for required verifications) 5. TOTAL CASH 6. TOTAL DEFERRED (Total deferred includes loans, mortgages, lines of credit, notes, etc. Attach copies of EACH source of deferred monies) 7. TOTAL INVESTMENT NOTE: The amounts in items 1 through 4 must total the amount reflected in item 7. The amounts in items 5 and 6 must total the amount reflected in item 7. IMPORTANT: Submit any and all records, documents and affidavits including loan agreements that you feel may assist you in explaining the source of monies as per instruction sheet. List lenders and amounts (to be) loaned from which "total deferred" will derive. Dollar(s) Amount Type of Investment ( Accounts, Loans, Gifts, Asset Sales, etc.) Source of Funds (Identify by Name - Lender, Giftor, Asset Sales, etc. - Provide Personal Questionnaires) Dollar(s) Amount Type of Investment ( Accounts, Loans, Gifts, Asset Sales, etc.) Source of Funds (Identify by Name - Lender, Giftor, Asset Sales, etc. - Provide Personal Questionnaires) Dollar(s) Amount Type of Investment ( Accounts, Loans, Gifts, Asset Sales, etc.) Source of Funds (Identify by Name - Lender, Giftor, Asset Sales, etc. - Provide Personal Questionnaires) Dollar(s) Amount Type of Investment ( Accounts, Loans, Gifts, Asset Sales, etc.) Source of Funds (Identify by Name - Lender, Giftor, Asset Sales, etc. - Provide Personal Questionnaires) continued on next page Page 5 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original whlsle-rev090211 Amended Date 28 List bank names and account numbers from which "TOTAL CASH" will derive. Dollar(s) Amount Type of Investment ( Accounts, Loans, Gifts, Asset Sales, etc.) Source of Funds (Identify by Name - Lender, Giftor, Asset Sales, etc. - Provide Personal Questionnaires) Dollar(s) Amount Type of Investment ( Accounts, Loans, Gifts, Asset Sales, etc.) Source of Funds (Identify by Name - Lender, Giftor, Asset Sales, etc. - Provide Personal Questionnaires) Dollar(s) Amount Type of Investment ( Accounts, Loans, Gifts, Asset Sales, etc.) Source of Funds (Identify by Name - Lender, Giftor, Asset Sales, etc. - Provide Personal Questionnaires) Dollar(s) Amount Type of Investment ( Accounts, Loans, Gifts, Asset Sales, etc.) Source of Funds (Identify by Name - Lender, Giftor, Asset Sales, etc. - Provide Personal Questionnaires) 8. Have all investors been disclosed in this application? YES NO The following person(s) MAY NOT invest in a wholesale 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 retail license. You must supply Personal Questionnaires for all investors or joint account holders Page 6 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original whlsle-rev090211 Amended Date 56 PREMISES 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 Describe in detail the building(s) in which the a. premises will be located and list the number of floors in the building. ( ie. : Entire building, office space - include suite number) 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 to traffic in alcoholic beverages? YES NO d. What was prior use of premises to be licensed? e. Does the proposed location of the business comply with all state and local regulations and zoning codes? YES NO f. 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.) g. Does any other person have access to this area? YES NO h. If applying for a Farm Winery License ,the premises must be located on a farm. In the box below, provide a detailed description of the premises and location of the vineyard in relation to the production site and location of a restaurant on or adjacent to the premises. (You must apply for a separate license if you have a restaurant for on premises consumption on or adjacent to the premises to be licensed.) (Provide additional sheets if necessary) continued on next page Page 7 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original whlsle-rev090211 Amended Date 56 PROPOSED METHOD OF OPERATION All applicants for a license to sell alcoholic beverages must complete this Section 1. Select the type of wholesale license you are applying for from the list below (based upon your intended method of operation): Alternating Propietorship/ Brewer - AB 101 Distiller Class D - DD 207 Brewer-D 101 Farm Winery/Special Farm Winery-FW 302 Cider Producer /Wholesaler - CD 304 Micro Brewer - MI 101 Cider Wholesaler (Beer Wholesaler) BC 104 Micro Winery - MW 307 Distiller Class ADA 201 Wholesale Beer- C 103 (* Beverage Center) Distiller Class A-1 DA 206 Wholesale Beer- CO 105 Distiller Class BDB 202 Wholesale Liquor-LL 203 Distiller Class B-1 - DB 205 Wholesale Wine - WW 303 Distiller Class C - DC 204 Winery/Special Winery -DW301 * = You may only apply for this license type if you are purchasing an existing license - Please provide a detailed statement explaining your planned method of operation. Describe the production method you will use to make your product. Include the quantity you intend to produce annually and who you intend to sell your product to. YOU MUST SUPPLY A COPY OF THE FEDERAL BASIC PERMIT SHOWING THE APPROVED TYPE OF OPERATION. 2. Will any other business of any kind be conducted in said premises? YES NO (If YES, provide details on a separate sheet) 3. How many employees? 3a. If answer is "0" provide explanation. 3b. 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: PLEASE CONTACT THE AUTHORITY AT 518-474-3114 OR VISIT OUR WEBSITE AT WWW.ABC.STATE.NY.US FOR INFORMATION REGARDING OTHER LICENSES OR PERMITS YOU MAY WANT OR NEED THAT COULD ALLOW ADDITIONAL PRIVILEGES. Page 8 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original whlsle-rev090211 Amended Date 42 PROOF OF CITIZENSHIP AFFIRMATION Applicants may submit, in lieu of proof of citizenship, a signed and dated copy of a naturalization certificate or green card with an affirmation on the copy submitted as follows: NOTE: This affirmation can only be submitted by an Attorney duly admitted to practice in the State of New York. All other representatives must present original proof(s) to be verified by the Authority personnel. Applicant/Individual Name: I, the undersigned, an Attorney at Law duly admitted to practice in the State of New York, have compared the original with this copy of: VISA ALIEN REGISTRATION CARD OTHER and affirms under the penalty of perjury that the foregoing copy is a true and complete copy of the original proof of citizenship. This affirmation is given to the Division of Alcoholic Beverage Control knowing that they will rely upon the same in review of the license application of: , and the applicant has signed his name directly in the space provided below. Signature of Applicant Date: Attorney must complete the following signature form: ATTORNEY INFORMATION: Attorney name: Office address: City, Town or Village: Telephone: Signature: State: Zip code: E-mail address: Date: Page 9 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original whlsle-rev090211 Amended Date 137 APPLICANT'S STATEMENT I, [print name] sole proprietor, corporate principal or LLC/LLP member ) partner, of the applicant for an Alcoholic Beverage Control License understand that the State Liquor Authority will ( the rely on each and every answer in the application and accompanying documents in reaching its determination and state, under penalty of perjury, that all statements and representations therein are true to the best of my knowledge and belief; and I state that the location and description of the premises to be licensed does not violate any requirement of the ABC law or other state or local ordinances; and I understand that if any change occurs in the information provided to the Authority in the application, the licensee must notify the Authority by certified mail within 48 hours and if any change occurs after receipt of the license, the licensee must notify the Authority by certified mail within 10 days. I understand that failure to give such notice may result in disapproval of the application or revocation or non-renewal of any license for which this application is submitted; and I understand that the licensee will be bound by the statements and representations made in the application, including, but not limited to the licensee's method of operation and the identity of persons with an ownership or financial interest in the licensed premises; and that all statements and representations made become conditions of the license; and I understand that any physical alterations to, or changes to the size of the area used for the sale and consumption of alcoholic beverages, must be reported to the Authority and may require the approval of the Authority; and I understand that the licensee must keep the Authority advised of any change in the mailing addresses of the licensee, the licensee's principals, and the licensee's landlord. I understand that the licensee's failure to operate the licensed premises in accordance with the statements and representations made in the application may result in revocation of any license for which the application was submitted; and I understand that any false statement or misrepresentation will constitute cause for disapproval of the application or revocation or non-renewal of any license for which this application is submitted. Signature Date Page 10 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY whlsle-rev090211 Date Amended Original 14 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 11 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original whlsle-rev090211 Date Amended 14 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 12 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original whlsle-rev090211 Date Amended 14 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 Date of filing Disposition Date of filing continued on next page Page 13 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY whlsle-rev090211 Original Amended Date 14 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 14 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Original whlsle-rev090211 Amended Date 14 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 15 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY Amended Original whlsle-rev090211 Date -136 STATE OF NEW YORK NOTICE OF APPEARANCE Section 166 of the Executive Law requires a regulatory agency to maintain for public inspection, a record of who appears before it, for a fee as a third party (i.e., an attorney, an agent, lobbyist*, or representative) on behalf of a person or organization subject to the regulatory jurisdiction of the agency. This usually occurs when the third party’s client is involved in an enforcement, formal permit, or application matter. This form is subject to all the rules and regulations of the Freedom of Information Law. Information that is confidential as a matter of law need not be furnished. Agency: Date: Division/Bureau: 1. Name of individual appearing: Address: Telephone: 2. Client represented: Address: Telephone: 3. Subject of appearance: Regulatory/Enforcement Lobbying 4. Acting in capacity of: Attorney Lobbyist Agent Other (describe) 5. Are you being compensated? Yes If Yes, Fee: No Salary: 6. Signature of individual appearing: 7. Agency official (print name): Signature: *A LOBBYIST is a person or organization, other than a New York State government employee acting in an official capacity, who appears for the purpose of influencing the adoption or rejection of proposed rules, regulations, rates, legislation, including the State budget or the specification or award of a State Procurement Contract. An "appearance” for lobbying purposes can be a personal visit, letter, telephone call, conversation at a meeting, or any other type of contact, but does not include “on the record” proceedings or hearings. Page 16 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY whlsle-rev090211 Original Amended Date STATE OF NEW YORK LIQUOR AUTHORITY 16 (Series 1953) Bulletin #254 December 1, 1953 TO: MANUFACTURERS AND WHOLESALERS SUBJECT: 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. The licensed premises must be physically separated from any other premises. 2. No other business may be conducted on the licensed premises. 3. The premises must be in charge of any employee of the licensee, and open during regular business hours. 4. 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. I have read and will comply with Bulletin #254 Signature Date Page 17 American LegalNet, Inc. www.FormsWorkFlow.com