ALL CLUB LICENSEES The following information is required in support of your application for an ABC Officer: ♦ Proof of Citizenship for proposed ABC Officer - acceptable identification for citizens of the U.S. include birth certificate or passport. ♦ A recent original color photo of the proposed ABC Officer no smaller than 2” x 2” with name printed legibly on back. ♦ $13 ABC Officer Appointment fee – made payable to the New York State Liquor Authority ♦ Personal Questionnaire of proposed ABC Officer ♦ Photo Identification - acceptable identification includes drivers’ license, non-driver’s identification issued by a government agency or Military identification. ♦ Completed Certification of Appointment of Alcoholic Beverage Control Officer signed by both the proposed ABC Officer and a current Officer of the Club that is not the proposed ABC Officer. ♦ Applicant’s Statement completed by the Proposed ABC Officer. ♦ ELECTRONIC FINGERPRINTING NOTE: Persons CURRENTLY licensed by the State Liquor Authority do not have to be fingerprinted. Each applicant required to be fingerprinted will be instructed to contact L-1 Enrollment Services after the successful submission of your applications. The fee for electronic fingerprinting is $105.00 and will be paid directly to L-1 Enrollment Services when you are fingerprinted. Please mail application to: New York State Liquor Authority Church Street Station PO Box 3817 New York, NY 10008-3817 (ABC Officer application) SLA Form 1031 revised 02/25/11 American LegalNet, Inc. www.FormsWorkFlow.com -86 CERTIFICATION OF APPOINTMENT OF ALCOHOLIC BEVERAGE CONTROL OFFICER The undersigned, being a duly elected officer of ____________________________________ the holder of club license Name of licensee number __________________________________ hereby certifies that ______________________________, license number name of member a member in good standing, residing at _______________________________________, has been appointed to serve as address the Alcoholic Beverage Control Officer for the club. This appointment shall remain in full force and effect until the State Liquor Authority shall be notified and shall have approved the appointment of a replacement Alcoholic Beverage Control Officer. Date: _________________________ ___________________________________________________ Officer of Club (not proposed ABC Officer) Title I hereby accept the appointment as Alcoholic Beverage Control Officer Date: _______________________________ __________________________________________________ Signature of Proposed ABC Officer (ABC Officer application) SLA Form 1031 revised 2/25/11 American LegalNet, Inc. www.FormsWorkFlow.com