Questions on Status of Application - (614) 644-3155 General Questions - (614) 644-2411 Office Hours - 8:00 - 5:00 Ohio Department of Commerce Division of Liquor Control 6606 Tussing Road, P.O. Box 4005, Reynoldsburg, Ohio http://www.com.ohio.gov/liqr CAUTION: ALLOW 6 TO 8 WEEKS FOR PROCESSING APPLICATION FOR "B" CLASS DISTRIBUTOR PERMIT THE FOLLOWING ITEMS MUST BE SUBMITTED ALONG WITH THIS APPLICATION FOR PROCESSING A. Application Processing Fee of $100.00 B. Application completed in its entirety, notarized and signed. C. If Individual, list Social Security Number on line provided. D. If Partnership, you must submit a completed DLC form 4031, along with a copy of the Partnership Agreement. E. If Corporation, you must submit a completed DLC form 4030. F. If Limited Liability Company, you must submit a completed DLC form 4032. Please be advised that any social security numbers provided to the Division of Liquor Control in this application may be released to the Ohio Department of Public Safety, the Ohio Department of Taxation, the Ohio Attorney General, or to any other state or local law enforcement agency if the agency requests the social security number to conduct an investigation, implement an enforcement action, or collect taxes. FAILURE TO RESPOND TO ALL QUESTIONS WILL RESULT IN THE RETURN OF YOUR APPLICATION. SECTION A CHECK CLASSES APPLIED FOR: Class and Fee B-1 B-2 B-3 B-4 B-5 Type of Business: If OTHER , please explain SECTION B $3,125.00 Wholesale distributor of beer purchased from the holders of A-1 permits and to import and sell to retail permit holders $ 500.00 Wholesale distributor of wine purchased from the holders of A-2 and B-5 permits to sell to retail permit holders $ 124.00 Wholesale distributor of wine to bottle, distribute, or sell sacramental wine for religious rites $ 500.00 Wholesale distributor of prepared and bottled highballs, cocktails, cordials, and other mixed beverages under 42 proof purchased from the holders of A-4 permits and to import and sell to retail permit holders $1,563.00 Wholesale distributor of wine to purchase wine from the holders of A-2 permits, to import wine in bulk or in containers, and to bottle wine for sale to wholesale or retail permit holders. INDIVIDUAL PARTNERSHIP CORPORATION LLC OTHER Applicant (Individual, Corporation, Limited Liability Company or Partnership): DBA (doing business as): Township (if outside city limits): Residence Phone #: Business Phone #: Mailing Address: (Name, Street Address, City & Zip): Address: City, State, & Zip: FOR DIVISION USE ONLY REMARKS: RCPT# Proc. Fee Pd: YES NO BCI Fee Amount Paid: $ ________ Permit Number Permit Premises Address: City: Applicant's Email Address: Zip Code: County: Attorney's Name: Phone # Coder: Taxing District: CLASS REVIEWER ACTION: Trans. Code DLC 4176 Bus. Type EOE/ADA SERVICE PROVIDER PAGE 1 FOR TTY USERS DIAL ORS 1-800-750-0750 REV. 12/2010 American LegalNet, Inc. www.FormsWorkFlow.com SECTION C 1. Do you or any partner, office holder, managing member, 5% stockholder or member, spouse, or other person involved in this permit hold or have any interest in another permit business? If YES, Give permit number & address on the line provided YES NO 2a. Have you or any partner, office holder, managing member, 5% stockholder or member, spouse, or other person involved in this permit ever been convicted of a felony or misdemeanor, including any alcohol-related offenses? If YES, attach a written explanation. 2b. If applicant is a sole proprietor or partnership, will spouse work on the permit premises? If YES, indicate spouse's full name 3. Have you or any partner, office holder, managing member, 5% stockholder or member, spouse, or other person involved in this permit ever been refused a permit, denied a renewal, or had a permit revoked from another state, by this Division, or the Liquor Commission? If YES, attach a written explanation. 4. Do you own the real estate on which the proposed business will be located? If NO, return a completed a signed and dated copy of your LEASE OR RENTAL CONTRACT, OR SUMMARY OF TENANCY RIGHTS form (DLC form 4085). 5. Will the applicant be the sole owner of the business and equipment? If NO, and the fixtures or equipment are rented, submit signed and dated copy of rental agreement. 6. Will any person, partnership, LLC, or corporation, excluding banks or building and loan associations, have ANY financial interest (such as money, loans, installment contracts, property or other interest) or share in the profits in your business or your property, real or personal? If YES, attach an affidavit with details. NOTE: Ohio Revised Code Section 4303.293 provides a criminal penalty for failure to answer this question completely and correctly. YES YES NO NO YES YES NO NO YES NO YES NO 7. If filing as an individual or partnership, is individual or all partners a U.S. citizen? 8. Do you or any partner, member, stockholder, officer, employee, spouse, or other person involved in this permit own any stock or have any interest in the business of a manufacturer, another wholesale distributor of alcoholic beverages, or any retail permit holder? If YES, attach a written explanation. 9. What is your Federal Basic Permit Number? DELIBERATE MISREPRESENTATION OF ANY OF THE INFORMATION ON THE APPLICATION CAN RESULT IN THE DIVISION'S REFUSING TO APPROVE THIS APPLICATION. YES NO YES NO NOTE: Your permit certificate is issued for a permit period that expires October 1st each year and is renewed annually on that date. If your permit is issued after April 1st, you will receive a 50% refund of the class fees paid, not including the $100.00 application fee. THE FOLLOWING MUST BE COMPLETED BY THE APPLICANT: State of Ohio, I, (Please Print) County, ss being first duly sworn, according to law, depose and say that the statements and answers made in the foregoing application are true. ___________________________________________________________________________ (Signature of Individual, Partner, Officer, Managing Member, or 5% or more Stockholder or Member) _____________________ (Title) _______________ (Date) (Residence Address) (To be completed by Notary Public) (City) (State) (Zip Code) (Area Code & Telephone Number) Sworn to before me and subscribed in my presence this ______________day of _____________________________________, 20 _____________. ________________________________________ (Notary Public) NOTE: ALL DOCUMENTS BECOME PART OF THE PERMIT FILE AND WILL NOT BE RETURNED PAGE 2-