NORTH CAROLINA ALCOHOLIC BEVERAGE CONTROL COMMISSION Location: 400 E. Tryon Road Raleigh NC 27610 (919)779-0700 AMOUNT FEE PAID: APPROVED MAIL TO ADDRESS ON BACK OF FORM DATE: RECEIVED BY: REJECTED BY: DATE: MANAGER CHANGE APPLICATION (Corporation/LLC) (Do Not Write Above This Line) A certified check, cashier's check or money order in the amount of $10.00 must be submitted with this application. PLEASE PRINT County: Date: (in which event takes place) Corporate Name LLC Name Trade Name of Business Location Address of Business City State Zip Code City Street Address State Zip Code Mailing Address of Business Street Address/PO Box Individual's Full Name (no abbreviations) First Middle Last Last 4 of Social Security # Date of Birth Resident Address: Street/Route Home Telephone #: ( ) City State Business Telephone #: ( Zip Code ) Pleas check the type(s) of ABC permit(s) and include the permit number for each held by the above location. Malt Beverage Brownbagging Fortified Wine Special Occasions Unfortified Wine Mixed Beverage Other It is a Crime to make a false statement to obtain an ABC permit. I certify under oath or affirmation that I am a resident of the State of North Carolina, or an applicant that has executed a power of attorney in accordance with GS 18B-900(a)(2)(b); that I am not less than 21 years of age; that I have not been convicted of a felony within the past three years, and if convicted of a felony before then, I have had my citizenship restored; that I have not been convicted of an alcoholic beverage or misdemeanor controlled substance offence within the past two years; and that I have not had any alcoholic beverage permit revoked within the past three years. Signature of Applicant Sworn to and subscribed before me this the _________day of ____________________, 20__________ My commission expires: Notary or other person qualified by law to administer oaths Note: Must be stamped or sealed by notary. American LegalNet, Inc. www.FormsWorkFlow.com FOR OFFICIAL USE ONLY Do not write below this line INVESTIGATIVE REPORT 1. Have you reviewed the application with the applicant to determine that it is complete and correct? Yes No 2. Does the applicant have any criminal record of disqualifying nature? Yes No If Yes, please explain: 3. Are there any reasons that this individual should not be approved as manager of this location? Yes No If Yes, please explain: Agent's Signature Date MAIL THIS APPLICATION TO: If sending by U.S. Postal Service (regular mail): If sending by U.S. Postal Service EXPRESS MAIL or by FEDEX/UPS: NC ABC COMMISSION 4307 MAIL SERVICE CENTER RALEIGH NC 27699-4307 NC ABC COMMISSION 400 E. TRYON ROAD RALEIGH NC 27610 Corporate Manager Change Application 11/10 American LegalNet, Inc. www.FormsWorkFlow.com