INSTRUCTIONS FOR AN ENDORSEMENT APPLICATION Partnership to Corporation: Must be the same people in each entity (no additions or deletions). Complete the following: Front of Application. Section II, Box L. Section III, Part B. Section IV. Section V. Submit Copy of: Certificate of Incorporation. Filing Receipt from Secretary of State. Statement signed by present owners stating that they are transferring ownership in the business to the corporation. Also, certify that they are the sole corporate principals in the corporation. NOTE: This same procedure may be used when transferring between corporations, and/or individuals. IT CAN ONLY BE DONE WHEN THE PRINCIPALS OF BOTH ENTITIES ARE EXACTLY THE SAME. SECTION II: CATEGORY H: Dissolution of partnership with Transfer to Remaining Partner or Partner(s). (Note: This may also be used to read ADDITION OF PARTNERS). Complete the following: Front of Application. Section II, Box H. Section III, Part A & B. Section IV. Section V. Submit: Agreement of Purchase of Interest. Personal Questionnaire. Documentation of Source of Funds to be Invested. Proof of citizenship. Photo ID. Electronic Fingerprinting (Please see enclosed instructions). ALL APPLICANTS WILL BE REQUIRED TO BE FINGERPRINTED ELECTRONICALLY SLA Form 180-046A (revised 9/09) American LegalNet, Inc. www.FormsWorkFlow.com SECTION I LICENSE NAME and ADDRESS CORRECTIONS Check each box which applies to you. No fee is required for Section I changes. 1. ( ) The Post Office is changing the street name or numerical designation of the licensed premises. 2. ( ) Local government has changed the street designation of your licensed premises. For these changes, supply a copy of the official Post Post Office or government notice authorizing the change. 3. ( ) Correction of a typographical error in your original license. Supply a copy of the filing receipt or approval 4. ( ) Amend the corporate name of the licensed premises (no change in ownership). from the County Clerk or Secretary of State 5. ( ) Change in the other name (dba) under which the business is known to operate. for name changes and a bond rider reflecting. 6. ( ) Change in name due to marriage or divorce. (Include copy of marriage certificate all name and/or address changes or divorce decree). SECTION II Please examine the categories below and check the box or boxes which best identify the change(s) which are appropriate. A separate fee is required for each change checked. CHANGE REQUESTED A. ( ) Death of Licensee (individual) Appointments of Executor or Administrator B. ( ) Death of Licensee (partner) Appointment of Executor or Administrator C. ( ) Receiver or Trustee D. ( ) Assignee for Benefit of Creditors E. ( ) Committee for Incompetent F. ( ) Conservator G. ( ) Trustee in Bankruptcy H. ( ) Dissolution of Partnership with Transfer to Remaining Partners I. ( ) Addition of Partner(s) J. ( ) To change your business from sole proprietorship to a corporation where the sole proprietor remains the sole stockholder, officer and director of the corporation K. 1. 2. ( ) ( ) DOCUMENTS NEEDED Supply Letters Testamentary or Administration and a copy of death certificate; provide a penal bond rider for each change requested identifying the change in the business entity. Supply Letters Testamentary or Administration and a copy of death certificate. Supply documentation of Court Authorization Supply copy of Dissolution of Partnership or other Contractual Agreement FEE REQUIRED If you have checked A. through H. and your license class is a GROCERY OR DRUG STORE, the fee for each box checked is …………………………. $ 13.00 ALL OTHER LICENSE TYPES the fee for each box checked is ……$ 64.00 Supply Personal Questionnaires, $75.00 for each Fingerprint Card Fingerprint Cards, bond submission: rider amending bond to reflect names of additional partners, financial documentation showing amount invested by each partner, if appropriate, and the source of the funding, proof of citizenship, color photograph(passport size) and photo identification for each additional partner. Provide a penal bond rider Your fee is…………………$13.00 in the name of the corporation, a copy of filing receipt, Date of Incorporation and Receipt Number from Secretary of State Attach copy of Court order and/or conveyance; provide a penal bond rider in the name of the new business entity; Personal Questionnaires and Fingerprint Cards for all unlicensed Transfer by Gift Transfer by Inheritance M1 Recipients or beneficiaries may use this form to create from their beneficial interest new sole proprietorships or new partnerships with the State Liquor Authority M2 Beneficiaries or recipients who qualify to form sole proprietorships may use this form to create a a corporation as described in Section Section J. Pay the fee indicated in this Section If your business type is for the retail sale of beer or wine your fee is…………..$ 64.00 If your business type is for the retail sale of liquor your fee is--------------------$ 128.00 American LegalNet, Inc. www.FormsWorkFlow.com SECTION III A. 1. ( ) Death of Stockholder Supply Letters Testamentary or Administration 2. ( ) Transfer of Stock to Recipient or Beneficiary Supply Limited Liability Company operating agreement with amendments, Personal Questionnaires and Fingerprint Cards for all incoming Members 4. ( ) To change officers or directors Supply Personal Questionnaires and when there is no sale of stock* Fingerprint Cards for all incoming officers or directors 5. ( ) To change stockholders or Supply Personal Questionnaires and stockholdings where there Fingerprint Cards for all incoming are fewer than 10 stockholders* officers or directors; a copy of the 6. ( ) A change involving 10% or more Contract of Sale of Stock or a of the stock or any change in statement signed by the transferee stockholdings which would setting forth full details of the increase the holdings of any one transaction including any considerstockholder to 10% or more of ation for such transfer; Statement of the stock where there are 10 or Finances (Form 180-021B) signed more stockholders* by the person executing the application; Notice of Appearance, if applicable. If your existing license costs more than $500 per year, your fee is --------------------------$ 128.00 If your existing license costs less than $500 your fee is--------------$ 13.00 3. ( ) To change Members of LLC* 7. ( ) To appoint new Officers and Directors when there is no sale of stock* Your fee is………………...$..13.00 (plus $75.00 per Fingerprint Card) If your existing license costs more than $500 per year, your fee is………………….……$128.00 (plus $75.00 per Fingerprint Card) If you existing license costs less than $500 per year, your fee is………………………$ 13.00 (plus $75.00 per Fingerprint Card) Supply Personal Questionnaires, Your fee is……………….. $13.00 Fingerprint Cards and $75.00 for (plus $75.00 per Fingerprint Card) each card for all incoming Officers and Directors\ * All applicants for these categories must also supply proof of citizenship if not a U.S citizen and original color photographs (passport size). TOTAL THE FEES DUE FOR ALL CHANGES AND WRITE THE AMOUNT HERE $_______________________ ATTACH CERTIFIED CHECK OR MONEY ORDER PAYABLE TO THE NEW YORK STATE LIQUOR AUTHORITY American LegalNet, Inc. www.FormsWorkFlow.com -37 STATE OF NEW YORK LIQUOR AUTHORITY APPLICATION FOR ENDORSEMENT CERTIFICATE CORPORATE CHANGE OR OTHER LICENSE CHANGES USE THIS FORM for changes or endorsements to existing licenses caused by: 1. Name changes or address corrections (no fee required). 2. Death of Licensee. 3. Court appointments of representative. 4. New owner by gift or inheritance. NOTE: Beneficiaries or recipients may form new proprietorships provided there are no other financial transactions involved. Similarly new partnerships may be formed by beneficiaries or recipients with the remaining partners of the initial partnership provided no other financial transactions are involved. 5. Change of business form from sole proprietorship to a corporation where the sole proprietor remains the sole stockholder, officer, and director of the corporation. Beneficiaries and recipients qualifying to form sole proprietorships may form a corporation as described in this Section. It will not be necessary to form an interim proprietorship. 6. Limited Liability Companies (LLC) change of members. 7. Corporate licensees to apply for permission to make a corporate change involving (1) change of officers or directors or, (2) where there are fewer than 10 stockholders, any change in stockholders or stockholdings, or (3) where there are 10 or more stockholders, any change involving 10% or more of the stock or any change in stockholdings which would increase the holdings of any one stockholder to 10% or more of the stock. DO NOT USE THIS FORM 1. As an application to change the type of license you currently hold. 2. As an application to remove your license business to a new location. 3. As an application for alterations or as an application for additional bars. ANY CHANGES REQUESTED WILL NOT BECOME EFFECTIVE UNDER THE ALCOHOLIC BEVERAGE CONTROL LAW UNTIL PERMISSION HAS BEEN GRANTED BY THE STATE LIQUOR AUTHORITY AND ANY AND ALL CONDITIONS OF APPROVAL ARE MET BY THE APPLICANT. TO BE COMPLETED BY ALL APPLICANTS: The licensee named below hereby notifies the State Liquor Authority of a proposed change for which it requests the Authority’s approval, and for which purpose it makes the following statements. SERIAL NUMBER OF THE LICENSE TO BE CHANGED: FULL NAME OF LICENSEE TRADE NAME (DBA) STREET ADDRESS OF LICENSED PREMISES POST OFFICE ADDRESS OF PREMISES (IF DIFFERENT) CITY, TOWN OR VILLAGE-ZIP CODE COUNTY CITY TOWN OR VILLAGE – ZIP CODE (IF DIFFERENT) Telephone Number IF THE PERSON OR COMPANY LISTED BELOW HAS BEEN PAID A FEE AS A THIRD PARTY TO REPRESENT YOU BEFORE THIS AGENCY, A NOTICE OF APPEARANCE MUST BE COMPLETED AND SUBMITTED WITH THIS APPLICATION. NAME OF ATTORNEY OR REPRESENTATIVE TELEPHONE NUMBER STREET ADDRESS COUNTY CITY, TOWN OR VILLAGE – ZIP CODE American LegalNet, Inc. www.FormsWorkFlow.com SECTION I PROPOSED LICENSEE NAME CHANGE PROPOSED TRADE NAME (DBA) CHANGE ADDRESS OF LICENSED PREMISES (IF DIFFERENT FROM ABOVE) POST OFFICE OF PREMISES (IF DIFFERENT) CITY, TOWN OR VILLAGE (IF DIFFERENT FROM ABOVE) SECTION II COUNTY (IF DIFFERENT FROM ABOVE) CITY, TOWN OR VILLAGE (IF DIFFERENT) Telephone Number IDENTIFICATION OF INDIVIDUALS Part A. Identification of decedents, incompetents, partners, and donors whose position or interest has changed or ended in connection with the changes requested in Section II. ________________________________ _____________________________________ _________________________________ ________________________________ _____________________________________ _________________________________ Part B. List below the names of all entities, managers, officers, directors, individual stockholders, individual partners, members of committee, assignees, receivers, trustees, executors, or conservators that are new parties in interest in the subject license. NAME PERCENTAGE OF INTEREST TITLE NO. OF SHARES __________________________________ ____________________________ _____________________ ________________ __________________________________ ____________________________ _____________________ ________________ __________________________________ ____________________________ _____________________ ________________ Part C. Identification of owners and individuals remaining in interest in the subject license. __________________________________ ____________________________ ____________________ ________________ __________________________________ ____________________________ ____________________ ________________ __________________________________ ____________________________ ____________________ ________________ All parties listed in B and C above must complete a Personal Questionnaire, Fingerprint Card, original color photo (passport size) and proof of citizenship. The cost for each fingerprint card is $75.00 and should be included with this application. NOTE: For any of the above, if financing is involved, please give details and supply copies of contracts, agreements, leases or any other legal document. APPLICATION CERTIFICATION I/WE, THE APPLICANT (S), CERTIFY THAT ALL PAPERS FILED IN SUPPORT OF THIS APPLICATION OR ANY APPLICATION FILED UNDER THE ALCOHOLIC BEVERAGE CONTROL LAW BY ANY PERSON HAVING ANY INTEREST, DIRECT OR INDIRECT, EITHER IN THE BUSINESS TO BE LICENSED, OR ANY LICENSE OR PERMIT, SHALL BE DEEMED A PART HEREOF AND CONSIDERED BY THE STATE LIQUOR AUTHORITY IN ACTING UPON THIS APPLICATION. I/WE, THE APPLICANT (S), UNDERSTAND THAT I/WE MUST COMPLY WITH ALL LOCAL ZONING, HEALTH, BUILDING AND FIRE LAWS PERTAINING TO MY PLACE OF BUSINESS AND NOTIFY THE CLERK OF MY LOCAL MUNICIPALITY OR IN THE CITY OF NEW YORK, THE APPROPRIATE COMMUNITY PLANNING BOARD, BEFORE APPLYING FOR OR RENEWING A LIQUOR LICENSE. I/we understand that the information I/we submit will be relied on by the State Liquor Authority in acting on this application. I/we understand that any false statements or misrepresentations shall constitute sufficient cause for the disapproval of the application and/or revocation, cancellation or non-renewal of any license which is issued or affected as a result of such application. I/we verify that all the above statements made by me are true. If any of the above information changes prior to receipt of the license or approval of the corporate change or endorsement, I/we will notify the Authority by registered or certified mail within 48 hours. If any changes occur after the issuance of the license or approval applied for, I/we understand that failure to give the required notice may constitute a violation of Section 110 of the Alcoholic Beverage Control Law and/or Rule 36.1j of the State Liquor Authority and will result in proceedings to revoke, cancel or suspend such license. American LegalNet, Inc. www.FormsWorkFlow.com I/WE, THE APPLICANT (S), CERTIFY THAT THERE ARE NO FINANCIAL TRANSACTIONS INVOLVED CONCERNING THE LICENSE APPLIED FOR EXCEPT AS DESCRIBED HEREIN. I/WE, THE APPLICANT (S), NOTED ON THIS APPLICATION CERTIFY THAT I/WE KNOW AND ATTEST TO THE VALIDITY OF THE CONTENTS OF THE ABOVE APPLICATION AND THE STATEMENTS CONTAINED THEREIN. SIGNATURE OF EACH PARTNER OR GENERAL PARTNER, LLC MANAGING MEMBER, OR A COPORATE OFFICER DATE HOME PHONE NUMBER ______________________________________________________ _________________ (___) __________________ ______________________________________________________ _________________ (___) __________________ ______________________________________________________ _________________ (___) __________________ DATE SIGNATURE OF INDIVIDUAL American LegalNet, Inc. www.FormsWorkFlow.com SECTION III COMPLETE ALL OF THE INFORMATION BELOW IF APPLYING FOR ANY CHANGE IN CORPORATE OFFICERS, DIRECTORS, STOCKHOLDERS OR STOCKHOLDINGS (If more space is needed, attach rider). Any false answer or statements made by the applicant constitutes perjury and will subject any license issued hereunder to revocation. 1. STOCKHOLDERS and STOCKHOLDINGS under the proposed change will be as follows: (Do not include retiring stockholders. If more than 10 stockholders, include only those who will hold 10% or more of the stock. Enter asterisk (*) to indicate changes.) Change Name of Stockholder Residence Address of Stockholder Citizenship Shares of Stock * (Name of Country) Common Preferred 2. OFFICERS and DIRECTORS under the proposed change will be as follows: (Do not include retiring officers and directors. Enter an asterisk (*) to indicate changes.) Change Names of Officers Residence Addresses Title Citizenship Age * And Directors (also specify if director) (Name of Country) 1. (a) Is any officer, director or stockholder interested directly or indirectly in any premises or business where any alcoholic beverage is manufactured or sold at wholesale or retail by stock ownership, interlocking directors, mortgage or lien on any personal or real property or by other means including loans? (b) If so, state name of each such person, address of the premises, nature of interest and date acquired. 1.(a) ________Yes _________No (b) Name & Address (street, city, zip code) Nature of Interest 2. (a) Has any of the new officers, directors or stockholders ever previously filed application for any license or permit under the Alcoholic Beverage Control Law of this state or country or of any other state or country, either as an Individual, co-partner or officer, or officer, director or stockholder of a corporation? (b) If so, state name in which application was filed, address of the premises, the date thereof and the disposition. Give license serial number if license or permit was issued. (c) Has such license or permit ever been revoked, cancelled, suspended or otherwise involuntarily terminated or has any other penalty been imposed in connection therewith at any time? (d) If so, state what action was taken, and date thereof. Date Acquired 2. (a) _________Yes ___________No (b) Name of applicant Address of premises (Street, City, Town or Village, State) Date filed, Disposition, and License Serial Number, if any (c) __________Yes ___________No (d) Action and date (Add Rider if more space is needed) 3. (a) Has any of the new officers, directors or stockholders 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 so, state date of conviction and crime or offense involved. In each case a CERTIFICATE OF DISPOSITION or a CERTIFICATE OF CONVICTION by the Court Clerk must be attached. 4. (a) Are there any arrests, indictments or summonses (except for traffic infractions) PENDING against any of the new officers, directors or stockholders? (b) If so, state thereof, crime or offense involved and name of each defendant. 3. (a )________Yes ____________No (b) Crime or Offense Date Name of person convicted 4. (a) _________Yes ____________No (b) Crime or offense Date Name of defendant American LegalNet, Inc. www.FormsWorkFlow.com 5. (a) Is any officer, director or stockholder a police commissioner or other police official or subordinate of any police department, sheriff, deputy or under sheriff, or any other police officer? (b) If so, state name and title of such person. 6. (a) State whether any person other than those mentioned has 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 or shares or will share, on a percentage basis or in any way, in the receipts, losses or deficiencies of the business, to any extent whatsoever other than by fixed salary. (The interests relinquished by retiring officers, directors or stockholders need not be set forth in answer to this question. Any interests retained by them, however, should be reported). (b) If so, set forth the names and addresses of such persons, the nature or percent or description of interest or share. 7. (a) Does licensee corporation now hold any license issued by the Liquor Authority for which the annual fee is $500 or more? (b) State total number of licensed premises now operated by licensee in New York State. (If more than one, attach list of such premises showing each serial number, name, address and county.) (c) Is any stock transfer contemplated? 5.(a)__________Yes ____________No (b) Name and Title 6. (a)__________Yes ___________No (b) Name Address Nature of Interest Date acquired (b) Number of licensed premises 7. (a)_______Yes ________No (c )_________Yes ________No The licensee represents that there have been no changes other than those set forth herein, in any of the facts required to be set forth in the application for license, and agrees that any application filed by it or by any of its officers, directors or stockholders, for any license or permit under the Alcoholic Beverage Control Law, and the occupation record submitted herewith, shall be deemed and made a part hereof and considered by the Authority in acting upon this Request for Approval of Corporate Change. _______________________________________________________________ certifies that he is ________________________________________________________ (TITLE) of the above named licensee corporation; that he knows the contents of the above application and the statements and answers therein; that the same are true of his own knowledge that he has been authorized by order of the Board of Directors of said corporation to make the statements and answers therein in behalf of said corporation with the same force and effort as if said corporation made such statements and answers itself. Dated __________________________________ _____________________________________________________________________ (Signature of Currently Authorized Officer) ________________________________________________________________ certifies that he is to be ___________________________________________________ (TITLE of the above named licensee corporation; that he knows the contents of the above application and the statements and answers therein; that the same are true of his own knowledge. Dated___________________________________ _____________________________________________________________________ (Signature of a Proposed Authorized Officer) OFFICIAL USE ONLY SLA ACTION: Approved DATE Disapproved By:_____________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com