APPLICATION FOR REPRESENTATIVES 1) Indicate type of permit you are applying for_____________________________________. 2) Full Name of Applicant_______________________________________Age _________. 3) Residence Address: Street: ________________________________________________. · City, Town, or Village:___________________________________________________. · Zip Code: __________________Telephone Number: __________________________. 4) Name of Manufacturer or Wholesaler ________________________________________. · License/Permit No. ______________________ Telephone No.__________________. · Address of Premises ____________________________________________________. (Street, City, Town or Village, State and Zip Code) · County _______________________________________________________________. · Between what streets (if outside city limits and not known by bldg.#, specify location in relation to nearest road/highway)_______________________________ _____________________________________________________________________. · Has any changes in facts occurred since the signing of the application for the currently held permit which has not been reported to and acknowledged by the State Liquor Authority in accordance with the provisions of the S.L.A. Law. Yes __________ No ____________ (check one) · If answer is yes, EXPLAIN ________________________________________________ ______________________________________________________________________. 5a) For Negotiator’s Permit only: Is the applicant duly licensed to manufacture or sell alcoholic beverages at wholesale level in the state or country in which it is located? Yes ( ) 5b) No ( ) If a foreign manufacturer please attach a copy of the license or a letter from the Consular or governmental agency. SLA form 1012 revised 02/02/2007 American LegalNet, Inc. www.FormsWorkFlow.com 5c) List below the names and addresses of the representative (only two permitted) who will be authorized to conduct negotiations: NAME 5d) ADDRESS Indicate the type and brand names of the alcoholic beverages which will be offered to wholesalers in New York. If additional space is needed, please attach a list of the brand names. 6) 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 ( ) 7) No ( ) If yes, please submit, in each case, a CERTIFICATE OF DISPOSITION or a CERTIFICATE OF CONVICTION by the Court Clerk. 8) Has the applicant or (if 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 business 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 ( ) If yes, set forth the location, any type of such business, the nature of the interest and the date when it was acquired. American LegalNet, Inc. www.FormsWorkFlow.com 9) Is the applicant or (if a partnership) any of the partners or (if a corporation) any of the officers, directors or stockholders a police commissioner or other police official, or subordinate of any police department, or a sheriff, deputy or under sheriff or any other peace officer? Yes ( ) No ( ) If yes, state name and title of such person. NAME TITLE THE FOLLOWING CERTIFICATION IS TO BE SIGNED AND DATED BY THE EMPLOYER OF APPLICANT 10) For Solicitors Permits -(Employers Name)________________________ certifies that (applicant’s name)__________________________will be employed by them, and that they have compared the applicant’s Drivers License or Non-Drivers ID photo with the applicant and that the enclosed DMV ID # and signature are that of the applicant. __________________________________________ (Signature of licensee or officer of corporation) 11) ___________________ (Date) State nature of business in which applicant is currently engaged:________________ _______________________________________________________________________ 12) Business Address: _______________________________________________________ ______________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com THE FOLLOWING PHOTO ID CARD AUTHORIZATION MUST BE COMPLETED AND SIGNED BY THE APPLICANT The State Liquor Authority produces Solicitor Permit Photo ID cards from records of the NYS Department of Motor Vehicles (DMV). If you have a current NYS Driver’s License or Non-Driver ID card, please provide your 9-digit DMV ID number in the spaces provided and read and sign the informed consent below. If you do not have a photo NYS Driver's License or Non-Driver ID card, please visit any nearby NYS DMV office to obtain a Non-Driver ID BEFORE you complete and return this application. INFORMED CONSENT: I authorize the State Liquor Authority and DMV to produce an ID card bearing my DMV photo. I also understand that the State Liquor Authority and DMV will use my DMV photo to manufacture all subsequent ID cards for as long as I maintain my Solicitor's Permit. I understand that I can withdrawal consent for the use of this digitized image at any time. Requests for withdrawal must be submitted in writing to the State Liquor Authority. DRIVER's LICENSE ID #: |__|__|__|__|__|__|__|__|__| _________________________________________ (Applicant Signature) ________________ (Date) American LegalNet, Inc. www.FormsWorkFlow.com THE FOLLOWING CERTIFICATION MUST BE SIGNED AND DATED BY INDIVIDUAL APPLICANT AND EACH MEMBER OF 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 these conditions. _____________________________________ ____________________________________ _____________________________________ ____________________________________ _____________________________________ _____________________________________ (Signature of applicant or of each partner) (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 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 conditions for the permit applied for and agrees to comply with these conditions. _____________________________________ (Signature of authorized officer) _____________________________________ (Street Address) _____________________________________________ (City, Town or Village) _____________________________________________ (Zip Code) (Telephone #) ____________________________________________ (Dated) Revised 02/02/2007 American LegalNet, Inc. www.FormsWorkFlow.com REPRESENTATIVES PERMITS FEE CHART CODE SE – 607 (pro-rated) TYPE OF PERMIT TEMPORARY SOLICITORS (3 Years) (2 Years) (1 Year) FEE ORIGINAL FILING FEE $114.00 $ 76.00 $ 38.00 $20.00 BOND FINGERPRINT NEEDED NO NO SP – 641 (pro-rated) SOLICITOR'S (3 Years) (2 Years) (1 Year) $ 78.00 $ 52.00 $ 26.00 $ 20.00 $1,000.00 YES BK – 642 BROKERS (3 Years) $768.00 $ 20.00 $1,000.00 YES NEGOTIATOR (3 Years) (2 ½ Years) (2 years) (1 ½ Years) (1 Year) $600.00 500.00 400.00 300.00 200.00 $ 20.00 NO NO NA – 647 (pro-rated by six months at a time) Revised 02/02/2007 American LegalNet, Inc. www.FormsWorkFlow.com WHERE TO FILE THE APPLICATION • Please mail your application to one of the State Liquor Authority Zone offices listed below which supports the county in which you will be doing business. ZONE 1 ZONE 2 ZONE 3 State Liquor Authority 317 Lenox Ave. New York, NY 10027 State Liquor Authority Alfred E. Smith Building 80 So. Swan St., Suite 900 Albany, NY 12210-8002 State Liquor Authority Iskalo Electric Tower Building 535 Washington St., Suite 303 Buffalo, NY 14203 Bronx Kings Nassau New York Queens Richmond Suffolk Westchester Albany Clinton Columbia Dutchess Essex Franklin Fulton Greene Hamilton Montgomery Orange Putnam Rockland Rensselaer Saratoga Schenectady Schoharie Sullivan Ulster Warren Washington Broome Cayuga Chenango Cortland Delaware Herkimer Jefferson Lewis Madison Oneida Onondaga Oswego Otsego St. Lawrence Allegany Cattaraugus Chautauqua Chemung Erie Genesee Livingston Monroe Niagara Ontario Orleans Schuyler Seneca Steuben Tioga Tompkins Wayne Wyoming Yates American LegalNet, Inc. www.FormsWorkFlow.com SECTION M PERSONAL QUESTIONNAIRE ♦ All principals to the license application must complete this questionnaire in full. ♦ Answer all questions below. ♦ Make duplicate blank forms as necessary. ♦ Attach additional sheets if more space is needed. NAME OF APPLICANT: 1. Statement of Identification Print YOUR name: Date of birth: Residence street address of above: Social Security number: County: E-mail address: City, State, Zip: Telephone number (residence): If NOT U.S. citizen - country of citizenship: U.S. citizen? YES If Alien, registration # or Visa type: NO List any other names that you have been known by (including maiden name): Height _____________________ Hair Color _____________________ Marital Status ___________________________________ Sex Eye color ______________________ Spouse Name ___________________________________ Male Female Spouses Social Security #: _________________________ Weight ____________________ 2. Residences for the past TEN years. (If more space is required, attach additional sheets): Address 3. Your occupation for the past TEN years. From/To (month/year) 4. From (month/year) To (month/year) Employer (If more space is required, attach additional sheets). Address Type of Business Position Position (or interest) you will hold in the license application (check each): President Vice President Secretary Treasurer Chairman Officer Director Stockholder Partner General Partner Limited Partner Sole Proprietor Manager Lender Donor Guarantor LLC Manager LLC Member OTHER American LegalNet, Inc. www.FormsWorkFlow.com 5. LICENSE HISTORY / AFFILIATIONS Section M YES NO YES NO YES If you are an applicant (i.e.: proprietor, partner, stockholder, officer or director) or applicant’s spouse, will you continue your present occupation or business? NO If YES, list hours you will devote to business sought to be licensed: Will you take an active part in the operation of the business to be licensed? If YES, explain nature of activity (hours, day, week): Do you have any interest, direct or indirect, in any premises currently licensed by the Liquor Authority or business where any alcoholic beverage is manufactured, transported or sold at wholesale or retail whether by stock ownership, interlocking directors, mortgage or lien on, or ownership of any real or personal property, or by any other means including loans? If YES, provide information below: Business Name Business Address Date Interest Began Other than as itemized in the above, have you ever applied in New York State, or Anywhere for a license or permit to traffic in alcoholic beverages, including Any application as a partnership or corporation in which you are/were a principal? Liquor License No. YES NO If YES, provide information below: Name of applicant Address of premises Date of filing Has a license or permit listed above been REVOKED, CANCELED Or otherwise Involuntarily Terminated? License No. Disposition YES NO YES NO If YES, state action and date of action, and give details: Are you a police commissioner, other police official, subordinate of any police Department, a Sheriff, Deputy, Under-Sheriff or any Peace Officer? If YES, provide details? American LegalNet, Inc. www.FormsWorkFlow.com 6. CONVICTION RECORD & PENDING CRIMINAL CASES (a) Have you or your spouse (or any officer, director, shareholder or partner listed in this application or the spouse of such person) been convicted of a crime addressed by the provisions of Section 126 of the ABC Law (see instructions for statutory disqualification) which would forbid a person to traffic in alcoholic beverages? Section M YES NO (b) Have you or your spouse (or any officer, director, shareholder or partner Listed in this application or the spouse of such person) ever been CONVICTED (including pleas of guilty or suspended sentences of any felony, misdemeanor (including driving while intoxicated or impaired) or any other type of offense EXCEPT MINOR TRAFFIC INFRACTIONS? YES NO (c) If YES, attach a Certificate of Disposition by the court clerk for each case And a Certificate of Relief from disabilities if available and submit an Affidavit explaining all details. If you have reported all convictions to this Authority and were subsequently approved for a license, check here: Approved: If YES, supply details (attach additional pages as necessary): (d) Are there any ARRESTS, INDICTMENTS or SUMMONSES other than minor traffic infractions PENDING against you or your spouse (or any officer, director, shareholder or partner listed in this application or the spouse of such person) – including driving while intoxicated or impaired? YES NO YES NO (e) IF YES, PROVIDE COPY OF ACCUSATORY INSTRUMENT. (f) 7. If you are an applicant (i.e. proprietor, partner, stockholder, officer or Director), would any of the above questions require a YES answer if asked of your spouse? INFORMATION CONCERNING AVAILABILITY OF PREMISES Explain how you became aware of the availability of the proposed premises. American LegalNet, Inc. www.FormsWorkFlow.com 8. FINANCES IMPORTANT: Section M Submit any and all records, documents and affidavits that you feel may assist you in explaining the source of monies you will provide the applicant as per instruction sheet. State TOTAL AMOUNT OF MONEY you are providing the applicant: Type of Investment (Investment Loan, Contract Debt) Type of Investment Dollar ($) Amount $ Source of Funds (Accounts, Loans, Gifts, Asset Sales, etc.) (enter identification numbers for accounts) If you are guaranteed a loan as a co-signer or putting up something of value as collateral. Identify Co-Signer or Collateral Identify Loan/Describe Collateral I understand that the information I submit will be relied upon by the State Liquor Authority and a false statement or misrepresentation will constitute cause for the disapproval of the application or revocation of any license for which this application is submitted. I verify that statements made herein are true and if any change occurs prior to the receipt of the license, I will notify the Authority by registered or certified mail within 48 hours or if change occurs after the receipt of the license, I will notify the Authority similarly within 10 days. I understand that failure to give the required notice will violate the Alcoholic Beverage Control Law and may result in revocation of the license. Signature of Applicant Date SLA form 1012 revised 02/02/2007 American LegalNet, Inc. www.FormsWorkFlow.com