-30 MISCELLANEOUS PERMITS Indicate type of permit you are applying for ______________________________________________ Present Permit No:__________________________________________________________________ 1) Full name of applicant or licensee__________________________________________________ (If partnership, name all 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 ____________________ 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.________________________________ 12) Specify the date for proposed event, sale, tasting by supplier, auction or semester dates of the class or course of classes to be given: __________________________________________________________ 12A) Indicate the name and address of the licensed establishment where the event, sale, tasting by supplier or auction will take place: • Name __________________________ • Trade Name _______________________ • Premises Address ___________________________________________________________ • City, town or village and zip code_______________________________________________ • License Number ____________________________ • Telephone No._________________ American LegalNet, Inc. www.FormsWorkFlow.com 13) Indicate the location where the alcoholic beverages are stored or where sale, class, auction or rectifying will take place____________________________________________________________ ________________________________________________________________________________ 13A) Name of Rectifier _________________________ License No. ____________________ 13B) Name of Instructor(s)______________________________________________________ 14) Does location where alcoholic beverages are stored have a warehouse permit? Yes ( ) No ( ) If Yes, permit # ______________Date of Issuance ____________ 14A) Will any other business of any kind be carried on in said premises? Yes ( ) No ( ) If yes, give details ________________________________________________________ 14B) Will any alcoholic beverages be subject to any processes while stored on said premises? Yes ( ) No ( ) 15) Does the applicant hold a transportation permit? Yes ( ) No ( ) 16) Please indicate how you came into possession of the alcoholic beverages________________ __________________________________________________________________________ 16A) Were they owned by a licensee or former licensee Yes ( ) No ( ) List name and license number __________________________________________________ __________________________________________________________________________ 17) For Fire Insurance/Salvage Co. Only - Name and address of licensed premises where fire occurred: __________________________________________________________________ __________________________________________________________________________ 18) Date the fire occurred: _______________________________________________________ 19) For Hotel-Off Premises permit (license)- state whether the premises for which this application is filed is within eight (8) miles in any direction of any premises licensed for off-premises sale of liquor or wine at retail _____________________________________________________ 20) 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 of any kind except traffic violations?: Yes ( ) No ( ) • If yes, a CERTIFICATE OF DISPOSITION or a CERTIFICATE OF CONVICTION by the Court Clerk must be attached. American LegalNet, Inc. www.FormsWorkFlow.com 21) Has any license or permit issued for the premises, or any part of the building containing such premises, ever been Revoked or Cancelled? Yes ( ) No ( ) • If so, state date and name of former licensee or permittee and specific location in the building where such business was conducted_____________________________________________ ____________________________________________________________________________ 22) Has any application been made, for said premises as any part thereof, for the issuance of a bonded warehouse permit, under the United State Customs Regulations. Yes ( ) No ( ) • If so, give date of such action, name of former licensee or permittee and the specific location in the building where such business was conducted under said license or permit: ____________________________________________________________________________ 23) Was an application for any license or permit under the Alcohol Beverage Control Laws of this state or country or any other state or country ever been made by the applicant, any partner or any officer of a corporation? Yes ( ) No ( ) • If so, state name of applicant________________________________________________ • Address of premises ______________________________________________________ • Date filed ____________________ Disposition _______________________________ • Has such license or permit ever been Revoked, Cancelled, Suspended or Otherwise Terminated or has any other penalty been imposed at any time? Yes ( ) No ( ) • If so, state what action was taken ____________________________________________ _________________________________________________________________________ ______________________________________________(add rider if more space is needed) 24) Please provide a detailed description of the alcoholic beverages to be stored or sold on an attached sheet. Indicate number of cases, Brand Name, Type and Size of containers. ________________________________________________________________________ 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/herself, certifies that he/she is the applicant above named; that he/she knows the contents of the above application and the statements contained therein and the same are true of his/her own knowledge. The undersigned certifies that he/she has read the conditions for the permit applied for and agree 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/she is __________________________________________ (Title) of the above named applicant corporation; that he/she knows the contents of the above application and the statements and answers therein; that the same are true of his/her own knowledge; that he/she 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 09/09 American LegalNet, Inc. www.FormsWorkFlow.com TO BE ANSWERED ONLY BY A CORPORATION A) State under what law applicant was incorporated and the date of incorporation. _________________________________________________________________ B) If a foreign corporation, state whether a certificate of authority has been obtained to do business in this state and the date thereof: _________________________________________________________________ C) Supply the following information for all OFFICERS and DIRECTORS of said corporation as of the date of filing this application. NAME RESIDENCE CITIZENSHIP NAME OF APPLICANT RESIDENCE CITIZENSHIP (if partnership, name each partner) TITLE TITLE AGE AGE THE APPLICANT HEREBY AGREES ANY APPLICATION FILED UNDER THE ALCOHOLIC BEVERAGE CONTROL LAW, BY ANY PERSON HAVING ANY INTEREST, DIRECT OR INDIRECT EITHER IN THE PREMISES OR IN THE BUSINESS TO BE LICENSED, FOR ANY LICENSE OR PERMIT SHALL BE DEEMED AND MADE A PART HEREOF AND CONSIDERED BY THE STATE LIQUOR AUTHORITY IN ACTING UPON THIS APPLICATION. APPLICANT UNDERSTANDS THAT ANY CHANGE IN ANY OF THE FACTS REPORTED HEREIN WHICH OCCURS BETWEEN THE SIGNING OF THIS APPLICATION AND THE ISSUANCE OF THE PERMIT MUST BE REPORTED TO THE AUTHORITY IN WRITING BY CERTIFIED OR REGISTERED MAIL WITHIN 48 HOURS. ANY CHANGE OF FACTS OCCURRING AFTER THE ISSUANCE OF THE PERMIT MUST BE REPORTED WITHIN 10 DAYS. THE FAILURE TO COMPLY WITH THE FOREGOING IS A GROUND FOR THE REVOCATION, CANCELLATION OR SUSPENSION OF THE PERMIT. MISCELLANEOUS PERMITS American LegalNet, Inc. www.FormsWorkFlow.com CODE TYPE OF PERMIT FEE ORIGINAL FILING FEE MB733 BANKING (ONE TIME) $ 26.00 $ 10.00 NO WB605 BOTTLING (LICENSEE) (3 YEARS) $ 1,440.00 $ 20.00 $5,000.00 BS646 BOTTLING (NON-LICENSEE) (3 YEARS) $4,800.00 $ 20.00 $5,000.00 FIRE INS. OR SALVAGE CO (ONE TIME) $ 20.00 $ 10.00 NO MW735 LIENOR (ONE TIME) $ 26.00 $ 10.00 NO HE-615 INSTITUTION OF HIGHER EDUCATION $256.00(annual) $ 26.00 (onetime) $20.00 $10.00 NO HOTEL OFF PREMISES (2 YEARS) $ 125.00 $200.00 NO LIQUIDATORS $ 26.00 $ 10.00 NO $ 26.00 $ 10.00 NO $ 20.00 (per 20 cases) $ 10.00 NO MF-732 HO-622 ML730 ME731 SHERIFF, MARSHALL, RECEIVER, EXECUTOR, ASSIGNEE MX612 PLENARY – STORAGE OFF SEASON (ANNUAL) BOND MC – 736 PLENARY (MISC - ONE TIME) $ 20.00 $ 10.00 NO PM-613 PLENARY (MISC - ANNUAL) $ 256.00 $ 20.00 NO American LegalNet, Inc. www.FormsWorkFlow.com RP-701 RECONDITIONING WR-603 RETAIL WINE SACRAMENTAL (WHOLESALER) WD-602 RETAIL WINE TO HOUSEHOLDERS (WINERY) S616 SUPPLIER PERMIT (LICENSED IN STATE SUPPLIERS AND UNLICENSED OUT OF STATE SUPPLIERS) - ANNUAL SUPPLIER PERMIT (LICENSED IN STATE SUPPLIERS AND UNLICENSED OUT OF STATE SUPPLIERS) – ONE TIME S748 WP, SW & WG 645 WAREHOUSE (3 YEARS) $ 26.00 (PER DAY) NONE NO $ 125.00 NONE NO $ 125.00 $ 20.00 NO $256.00 $20.00 NO $ 90.00 $10.00 NO $ 768.00 $ 20.00 $5,000.00 Revised 09/09 American LegalNet, Inc. www.FormsWorkFlow.com