CONDITIONS FOR TEMPORARY RETAIL PERMIT IMPORTANT: This application must be accompanied by: • ONE SET OF RECENT PREMISE PHOTOGRAPHS NO SMALLER THAN 4” X 6” IN SIZE • ONE COPY OF THE CONTRACT OF SALE OR CONVEYANCE. The subject premises must have been operated under a retail license within thirty days of the filing of the application for this permit. This application may be filed simultaneously with the application for transfer, or an application for transfer must be on file with the Division of Alcoholic Beverage Control. This is a conditional permit in that it authorizes the holder to traffic in alcoholic beverages only as would be permitted under the privileges of the current license which it replaces. Both the buyer and the seller understand and accept that issuance of this temporary permit is NOT a guarantee of approval of the application for transfer of the existing license to the applicant as filed by the buyer. It is also accepted that the Authority is held harmless for any hardship subsequent DISAPPROVAL of said application may create for both the buyer and the seller. The permit holder may purchase alcoholic beverages only by currency, money order, or certified check on or before delivery of beverages to the premises, unless the permit holder already holds another retail license and is not in violation of Alcoholic Beverage Control Law 101-a. This permit is granted at the discretion of the State Liquor Authority for a period of ninety days, and may similarly be renewed for an additional thirty days. This permit may be summarily cancelled or suspended at any time, if the NYS Liquor Authority determines that good cause exists for such suspension or cancellation. FEES Fee is payable upon filing, and must be a personal check, certified check or money order, payable to the NYS Liquor Authority. The fee is not refundable. INITIAL FEE Retail beer permit ……………………………………..$ 128.00 Any other retail permit ……………………………….. $ 640.00 30 DAYS EXTENSION FEE: Retail beer permit …………………………………….. $ 64.00 Any other retail permit ……………………………….. $ 96.00 American LegalNet, Inc. www.FormsWorkflow.com -35 Expiration/Surrender/Safekeeping Date:__________ Pending Disciplinary-Location ___YES ___NO Pending Disciplinary-Principals ___YES ___NO NEW YORK STATE LIQUOR AUTHORITY Original Renewal APPLICATION FOR TEMPORARY RETAIL PERMIT TO TRANSFEREE OF LICENSED PREMISES [See Reverse Side for Conditions of Issuance] NAME OF APPLICANT____________________________________________________________ ______/____/______ Date Filed SERIAL NUMBER OF CURRENT LICENSE:____________________________________________________ NAME OF CURRENT LICENSEE: _____________________________________________________________________ ADDRESS OF LICENSED PREMISES: _________________________________________________________________ PREMISES PHONE #: _______________________ REPRESENTATIVE’S PHONE #: _________________________ As an authorized signatory of the current applicant, I certify: that this is a bonafide business transfer between the licensee as transferor, and the applicant as transferee; and that the premises has been open and operating under the current license within 30 days of the above filing date. ______________________________ TITLE _____________________________________ _____________________________ APPLICANT’S SIGNATURE DATE The above party agrees that any false statement in the above certifications will constitute cause for disapprovals of the permit and the license applications. FOR OFFICIAL SLA USE ONLY - DO NOT WRITE IN THIS BOX Serial Number: ________________________________ SLA ACTION Fee Amount: __________________________________ Approved Disapproved Date of Issuance: ______________________________ Effective From: _____________To: ______________ Date: ___________________ By: ______________________ Sla Form: 180-058 (revised 4/24/2009) American LegalNet, Inc. www.FormsWorkflow.com