Form 805 MW (06/26/07) STATE OF NEW YORK LIQUOR AUTHORITY □ BC Wholesale Cider □ CD Cider, Producer PETITION FOR REMOVAL (Manufacturer or Wholesaler) □ □ C Wholesale Beer D Brewer □ □ DB Distiller Class “B” □ □ DC Distiller Class “C” □ DA Distiller Class “A” DW Winery LL Wholesale Liquor or Wholesaler □ WW Wholesale Wine This petition is to be used by the holder of a MANUFACTURER’S or WHOLESALER’S LICENSE to request permission to remove the licensed premises to a new location. This petition must be filled out and signed by the licensee and filed with the appropriate zone office of the county in which the premises to be licensed are located together with CHECK, or DRAFT, or MONEY ORDER for the removal application fee prescribed in Section 99-d, subd. 3 of the Alcoholic Beverage Control Law as follows: $192.00 where the basic annual license fee is $500 or more; $ 32.00 in all other instances. (The Law does not provide for any refund of fees prescribed in Section 99-d.) ALL QUESTIONS MUST BE ANSWERED IN BOXES BELOW. (If more space is needed, attach rider.) Any false answer or statement made by the applicant constitutes perjury and will subject the applicant’s license to revocation. The licensee named below hereby requests the permission of the Liquor Authority for the REMOVAL of the present licensed premises to the proposed premises set forth below. Full name of applicant – licensee Trade name or other designation License No. PRESENT PREMISES (street address) Post Office address Serial No. City, town or village – Zip Code Telephone No. City, town or village – Zip Code County PROPOSED PREMISES Street address of premises to be licensed City, town or village – Zip Code Post office address of premises County City, town or village – Zip Code Between what streets or avenues. (If outside city limits and not known by a house number, give nearest intersecting road or highway.) What specific location in the building where applicant’s business is to be conducted. (If office building, give room numbers.) Name of owner of building Address of owner of building 1. Is any license under the Alcoholic Beverage Control Law now in effect for: 1. (a) Yes or No Name of licensee (a) The premises for which this application is filed? If so, give license number and full name of licensee. (b) Any other part of the building containing the premises? If so, give license number and full name of licensee. 2. (a) Will applicant occupy said premises under a written lease or option to lease? (b) If so, state name and address of immediate leasor, date of lease, and date of expiration thereof. (c) Do the terms of such lease require payment by the applicant of any consideration based on a percentage of the receipts of the business? (d) If so, state percentage and details. License Number Yes or No License Number (b) Name of licensee Yes or No 2. (a) Yes or No (c) Date of lease Date of expiration (b) Percentage and details (d) American LegalNet, Inc. www.FormsWorkflow.com STATE OF NEW YORK LIQUOR AUTHORITY PETITION FOR REMOVAL (Manufacturer or Wholesaler) Page 2 Yes or No 3. Will any other business of any kind be carried on in said premises? If so, give details. 3. Details Yes or No 4. Are the proposed premises located in an area zoned for residential, business or industrial use? Type of Zone 4. Yes or No 5. Are proposed premises located within 200 feet of a building occupied exclusively at a school, church, synagogue or other place of worship which is located on the same street or avenue? 6. 5. Reason for requesting permission for removal: THE FOLLOWING CERTIFICATION MUST BE SIGNED AND DATED BY INDIVIDUAL APPLICANT AND EACH MEMBER OF PARTNERSHIP The undersigned, each for themselves, certifies that he/she is the applicant above named; that he/she knows the contents of the above application together with all other papers filed in support thereof and the statements contained therein and the same are true of their own knowledge. Dated: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ (Signature of Petitioner or of each partner) THE FOLLOWING CERTIFICATION TO BE SIGNED AND DATED IF A CORPORATION ________________________________________________________certifies that he/she is ______________________________________________ (Print name) (Title) of the above named applicant corporation; that he/she knows the contents of the above application together with all other papers filed in support thereof and the statements and answers therein; that the same are true of his own knowledge; that he/she has been authorized, by order of the Board of Directors of said applicant corporation to make the statements and answers in this application in behalf of said applicant corporation with the same force and effect as if said corporation made such statements and answers itself. Dated: ________________________________________________________________________ ________________________________________________________________________ (Signature of Authorized Officer) STATE LIQUOR AUTHORITY’S ACTION: APPROVED SLA Form 805 MW (06/26/07) DISAPPROVED American LegalNet, Inc. www.FormsWorkflow.com