614 | 644 3155 Fax 614 | 644 3166 TTY/TDD 800 | 750 0750 www.com.ohio.govAn Equal Opportunity Employer and Service Provider6606 Tussing RoadPO Box 4005Reynoldsburg, OH 43068-9005 U.S.A. Affiliation AgreementPlease complete this form entirely, including signature by both the Hotel Officer and Permit Holder:This is to certify that Hotel NameauthorizesPermit Applicant Nameto serve liquor to hotel guests upon request, during all hours of legal operation, however the permit holder will assume all liability. Permit Applicant Signature: Rev. 5/8/2019By signing below, each party approves the affiliation agreement for the purpose of processing theD-5a liquor license.Hotel Officer Signature:LIQ-18- 0033DLC4255 FOR OFFICE USE ONLY:Permit # NewTransferRen American LegalNet, Inc. www.FormsWorkFlow.com