For Questions call (614) 644-3155 Office Hours 8:00 a.m. to 5:00 p.m. Ohio Department of Commerce Division of Liquor Control 6606 Tussing Road, P.O. Box 4005, Reynoldsburg, Ohio 43068-9005 http://www.com.ohio.gov/liqr APPLICATION FOR D-4 (CLUB) PERMIT ALLOW 10 TO 12 WEEKS FOR PROCESSING A. B. C. THE FOLLOWING ITEMS MUST BE SUBMITTED FOR YOUR APPLICATION TO BE ACCEPTED FOR PROCESSING Processing Fee of $100.00 (Non-Refundable). Application completed in its entirety, notarized and signed. Club Officer's Statement. CHECK CLASSES APPLIED FOR: Class and Fee D-4 $469.00 - Club Permit D-6 $500.00 - Sunday Sales Club or Corporate Name: DBA (doing business as): Township (if outside city limits): Residence Phone #: Mailing Address Information: Name: Attorney's Name: Email Address: Address: City, State, & Zip: Address: City, State, & Zip: Phone # City: Business Address: Zip Code: Business Phone #: County: SECTION A 1. Have you or any partner, office holder, managing member, 5% stockholder or member, spouse or other person interested in this permit ever been convicted of a felony or misdemeanor, including any alcohol-related offenses? If YES, attach a written explanation. 2. Do you own the real estate on which the proposed business will be located? If NO, return a completed signed and dated copy of your LEASE OR RENTAL CONTRACT, OR SUMMARY OF TENANCY RIGHTS form (DLC form 4085). 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. 5. Date when club was organized 6. How long has the club been continuously engaged in carrying out the purposes of the club 7. Name and address of national organization with which affiliated, if any YES NO YES NO YES NO FOR DIVISION USE ONLY Coder: Taxing District: Permit Number DLC 4171 FOR TTY USERS DIAL ORS 1-800-750-0750 EOE/ADA SERVICE PROVIDER Rev. 09/2013 American LegalNet, Inc. www.FormsWorkFlow.com Receipt # Remarks: Reviewer Action: SECTION B: COMPLETE ONLY IF APPLYING FOR A D-6 8. If currently selling alcohol or if a new business not currently selling alcohol, what percentage of your total gross receipts is currently, or will you estimate to be, attributed to the sale of food and other goods (excluding alcoholic beverages)? Your permit certificate is issued for a permit period that expires on either February 1, June 1 or October 1, depending on the county where your permit is located, and is renewed annually on that date. If your permit is issued within six months of the expiration date, you will receive a 50% refund of the class fees paid, not including the $100.00 application fee. Renewal dates by county may be found by visiting our web site at http://www.com.ohio.gov/liqr/docs/LIQR_RenewalDistricts.pdf. SECTION C: IF AN ASSOCIATION, COMPLETE THE FOLLOWING: State of Ohio, I, (Please Print) elected and qualified (Title) of the , an association duly County, ss being first duly sworn, according to law, deposes and says that he/she is the duly organized for the purpose and purposes herein stated, and that the statements and answers made in the foregoing application are true. ___________________________________________________________________________ (Signature of Officer) _____________________ (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 ________________________________, _____________________ ________________________________ ___________________ (Notary Public) (Notary Expiration) IF A CORPORATION, COMPLETE THE FOLLOWING: State of Ohio, I, County, ss being first duly sworn, according to law, depose and say that the statements (Please Print) and answers made in the foregoing application are true. __________________________________________________________________________________ (Signature of Individual, Partner, Officer, Managing Member, or 5% or more Stockholder or Member) (Residence Address) (City) (State) ________________ (Title) _______________ (Date) (Zip Code) (Area Code & Telephone Number) (To be completed by Notary Public) Sworn to before me and subscribed in my presence this ______________day of _____________________________________, 20 _____________. ________________________________________ (Notary Public) DLC 4171 PAGE 2 _______________ (Notary Expiration) Rev. 09/2013 American LegalNet, Inc. www.FormsWorkFlow.com GENERAL INSTRUCTIONS FOR FILING NEW D-4 APPLICATION Your application for a new D-4 permit will require you to file a D-4 application DLC 4171 form, together with documents referred to in Section A below. In addition, you are asked to have certain documents available for our Compliance Officer to review and inspect. The papers needed are listed below in Section B. SECTION A. A. B. C. D. E. F. COMPLETE AND RETURN TO THIS OFFICE: Club Officers Statement (DLC Form 4050). Summary of Tenancy Rights (DLC Form 4085). Certificate of Continued Existence, if a non-profit corporation. Name and telephone number of member to be contacted to schedule investigation. Submit check for $100.00 Processing fee, and permit fees. May be included in same check. Background Checks must be completed, therefore, PLEASE READ DLC4191. SECTION B. 1. ADDITIONAL DOCUMENTATION THAT MAY BE REQUIRED DURING THE PROCESS OF YOUR D4 APPLICATION Make certain you indicate the "Club or Corporation Name" on page 1 of the application. The name of the actual business may then be listed under "DBA" (doing business as). An individual or a majority of the partners in a partnership must have been a resident of the State of Ohio for at least one (1) year prior to filing an application. All individuals and partners must have U.S. Citizenship. (This does not apply to stockholders in a corporation, or members in an LLC). ISSUANCE OF PERMITS IS SUBJECT TO THE WET OR DRY STATUS OF THE LOCATION, AND MAY BE SUBJECT TO THE EXISTENCE OF AN OPENING UNDER THE QUOTA. Return the application, all fees, and all required documents to: OHIO DEPARTMENT OF COMMERCE - DIVISION OF LIQUOR CONTROL 6606 TUSSING ROAD, P.O. BOX 4005 REYNOLDSBURG, OHIO 43068-9005 2. 3. 4. WARNING: NO permit will be issued until the proposed business is ready for operation and meets Division regulations. ALL CONSTR