STATE OF NEW YORK SLA Form LB 33 (revised 06/02 ) LIQUOR AUTHORITY CERTIFICATE OF SERVICES 1. in the: 2. ( ) Removal of License from ( ) License for premises located at _________________________________________ ( ) Corporate change for (Number) (Street) The undersigned is an applicant for: ( ) city ( ) town of _____________________________________________________________________________, State of New York ( ) village The undersigned certifies that in connection with the preparation, filing and subsequent handling of the said application, the undersigned has engaged the services of the following attorney(s) representative(s) or agent(s) to represent or assist him and that no one else has been engaged to represent or assist him. (The employment of photographers, surveyors or draftsmen need not be set forth.) NAME ADDRESS PROFESSION OR BUSINESS FEE BASIS YES ( ) NO ( ) TELEPHONE NO.--------------------------------------(If the applicant has not been represented or assisted by any person it should be so stated) 3. The undersigned has made (no) (the following) arrangements for such representation or assistance upon a basis contingent upon the approval by the State Liquor Authority of this application. (List any compensation made or to be made pursuant to contingent arrangement.) It is further certified that no money, property or other thing of value has been paid, given or promised by the undersigned or by any one else on behalf of the undersigned to (my) (our) (its) knowledge or at the request of the undersigned to any attorney, representative or agent, other than those enumerated in paragraph “2” hereof, for representing or assisting the undersigned in any capacity (other than photographer, surveyor or draftsman) in connection with the said application except as follows: (IF NONE, SO STATE) The undersigned further certifies that it is understood that this certificate is to be attached and made part of the said application and that in action thereon the Liquor Authority will rely upon the representations herein contained. The undersigned understands that if there is any change with respect to any of the facts herein set forth, during the pendency of the application, such change must be reported to the Authority IMMEDIATELY by the undersigned and that if any change occurs after the issuance of the license applied for such change must be reported the Liquor Authority within ten (10) days of the date of such change. It is further understood that failure to give the requisite notice will constitute a violation of the Alcoholic Beverage Control Law and will result in proceedings to revoke, cancel or suspend such license. If an Individual or Partnership, Sign here If a Corporation, Sign here ______________________________________________________________ _______________________________________________________ (Corporation Name) ______________________________________________________________ By____________________________________________________ (Applicant’s Signature) (Authorized Person) THE FOLLOWING CERTIFICATION MUST BE SIGNED AND DATED BY INDIVIDUAL OR PARTNERSHIP The undersigned, each for himself, certifies that he is the applicant herein; that he has read the foregoing certification and knows the contents thereof; that the same is true of his own knowledge. Dated__________________________________ ______________________________________________________ ______________________________________________________ (Applicant’s Signature) THE FOLLOWING CERTIFICATION TO BE SIGNED AND DATED IF A CORPORATION _____________________________________________________ certifies that he is the ____________________________________________ of the above named applicant corporation; that he has read the foregoing certification and knows the contents thereof; that the same is true of his own knowledge; that he has been authorized by the Board of Directors of said applicant corporation to make the statements and answers in this certification in behalf of said corporation with the same force and effect as if said corporation made such statements and answers itself. Dated ______________________________________ __________________________________________________ (Signature of Authorized Officer) American LegalNet, Inc. www.FormsWorkflow.com