-30 MISCELLANEOUS PERMIT II Indicate type of permit you are applying for___________________________________________ Present Permit Number __________________________________________________________ 1) Full name of applicant or licensee (Partners) _______________________________________ __________________________________________________________________________ 2) Street Address of Licensed Premises ____________________________________________ __________________________________________________________________________ 3) City, town or village - Zip Code ________________________________________________ ________________________________________________________________________ 4) County _________________________________________________________________ 5) Trade Name (d.b.a.) ______________________________________________________ 6) License Number _______________________ Date Issued__________________ 6a) Type of License _________________________________________________________ 7) Post Office address of premises_____________________________________________ ______________________________________________________________________ 8) City, town or village - Zip Code______________________________________________ 9) Telephone Number ______________________________________________________ 10) Between what streets (if outside city limit and not known by bldg.#, specify location in relation to nearest road/highway): _________________________________________________________ _____________________________________________________________________ 11) Title (if applicable) Marshall, Receiver, Executor, etc. ___________________________ ________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 12) Indicate type of license and license # _____________________________________ ___________________________________________________________________ 13) For manufacturers- identify the products you manufacture which contain alcohol: __________________________________________________________________ 14) Does applicant own and operate or charter and operate aircraft or vessels for which it will purchase alcoholic beverages for ships stores? _____________________________ 15) Has the applicant or (if partnership) any of the partners or (if a corporation) any of the officers, directors or stockholders, or any agent or employee of the applicant, ever been CONVICTED (including pleas of guilty or suspended sentences) of any felony or of any other crime or offense ofany kind except traffic violations? YES ( ) NO ( ) 16) If yes (Quest. 15), please submit in each case a CERTIFICATE OF DISPOSITION or a CERTIFICATE OF CONVICTION by the Court Clerk. 16A) Has the applicant or (if a partnership) any of the partners or (if a corporation) any of the officers, directors or stockholders any interest, directly or indirectly, in any premises or buisness where any alcoholic beverage is manufactured or sold at wholesale or retail, whether by stock ownership, interlocking directors, mortgage or lein on, or ownership of any real or personal property, or by any other means including loans? YES ( ) NO ( ) 17) For manufacturers of Non-Beverage Products: indicate the type of products you manufacture which are unfit for beverage use: _______________________________________________________________________ _______________________________________________________________________ 18) For Distributors Alcohol Permits: (Complete this section) State whether any other business of any kind will be carried on in said premises. YES ( ) NO ( ) If so, state type of business:_______________________________________________________ State how long applicant has been engaged in such business._____________________________ State whether applicant holds any Federal permit of any kind whatsoever. ______________________________________________________________________________ If so, give full details regarding the same, including the amount of alcohol which may be purchased thereunder and purpose for which it will be used. ________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com State whether applicant owns, leases or operates any branch office, warehouse, storage or distributing plant other than at the premises to be licensed. _________________________________________________________________________________ If so, give the address of such other premises and the purpose for which the alcohol will be used: _________________________________________________________________________________ 19) For Industrial Alcohol, Non-beverage manufacturer, state the purpose for which the alcohol will be used: _________________________________________________________________________________ 20) Has the applicant filed simultaneously with this application an application for any other type of license for the premises for which this application is filed for. Yes ( ) No ( ) Revised 06/2002 American LegalNet, Inc. www.FormsWorkFlow.com THE FOLLOWING CERTIFICATION MUST BE SIGNED AND DATED BY INDIVIDUAL APPLICANT AND EACH MEMBER OF A PARTNERSHIP The undersigned, each for himself, certifies that he is the applicant above named; that he knows the contents of the above application and the statements contained therein and the same are true of his own knowledge. The undersigned certifies that he/she has read the conditions for the permit applied for and agrees to comply with those conditions. _____________________________________ __________________________________________________ _____________________________________ __________________________________________________ _____________________________________ _________________________________________________ (Signature of applicant or of each partner) _____________________________________ (Print Name) (Residence) (Home Phone) ____________________________________ (Dated) THIS CERTIFICATION TO BE SIGNED AND DATED BY A CORPORATION _____________________________________ certifies that he is _______________________________________ (Title) of the above named applicant 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 applicant corporation, group or association to make the statements and answers in this application in behalf of said corporation with the same force and effect as if said corporation made such statements and answers itself. The undersigned certifies that he/she has read the terms and conditions for the permit applied for and agrees to comply with those conditions. ___________________________________________ (Signature of authorized officer) ______________________________________________________ (Print Name) __________________________________________ (Street Address) _________________________________________________ (City, Town or Village) ______________________________________________________ (Zip Code) (Telephone #) ______________________________________________________ (Date) Revised 1/06 American LegalNet, Inc. www.FormsWorkFlow.com