OHIO DEPARTMENT OF COMMERCE DIVISION OF LIQUOR CONTROL 6606 TUSSING ROAD REYNOLDSBURG, OHIO 43068-9005 Telephone No. (614) 644-3155 APPLICATION FOR G PERMIT PERMIT FEE - $100.00 APPLICATION PROCESSING FEE - $100.00 http://www.com.ohio.gov/liqr § 4303.21 G permit. Permit G may be issued to the owner of a pharmacy in charge of a licensed pharmacist to be named in the permit for the sale at retail of alcohol for medicinal purposes in quantities at each sale of not more than one gallon upon the written prescription of a physician or dentist who is lawfully and regularly engaged in the practice of the physician's or dentist's profession in this state, and for the sale of industrial alcohol for mechanical, chemical, or scientific purposes to a person known by the seller to be engaged in mechanical, chemical, or scientific pursuits; all subject to section 4303.34 of the Revised Code. The fee for this permit is one hundred dollars. CAREFULLY READ THE GENERAL INSTRUCTIONS FOR FILING G APPLICATION TYPE OR PRINT PLAINLY Name of Applicant (Individual, Partnership, Corporation, or LLC : Business Address: City: Mailing Address: City: Residence Address: City: Name of Registered pharmacist(s) in Charge of Pharmacy : State: Residence Address: City, State, & Zip: Zip Code: Ohio Pharmacist Registration # State: Zip Code: County: State: Zip Code: Township (if outside city limits): ALL QUESTIONS MUST BE ANSWERED How long have you been in business at this location? Address: City, State, & Zip: Attorney's Name: Phone # ANSWER ALL QUESTIONS ON PAGE TWO FOR DIVISION USE ONLY Coder: Taxing District Permit Number Receipt # DLC 4080 EOE/ADA SERVICE PROVIDER Page 1 FOR TTY USERS DIAL ORS 1-800-750-0750 Rev. 7-07 American LegalNet, Inc. www.FormsWorkFlow.com Remarks: Reviewer Action: 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 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. Do you or any partner, office holder, managing member, 5% stockholder or member, employee, spouse, or other person involved in this permit own any stock or have any interest in the business of a manufacturer or wholesale distributor of alcoholic beverages? If YES, attach a written explanation. YES NO YES YES NO NO YES YES NO NO YES NO YES NO DELIBERATE MISREPRESENTATION OF ANY OF THE INFORMATION ON THE APPLICATION CAN RESULT IN THE DIVISION'S REFUSING TO APPROVE THIS APPLICATION. THE FOLLOWING MUST BE COMPLETED BY THE APPLICANT: State of Ohio, I, and answers made in the foregoing application are true. ___________________________________________________________________________ (Signature of Individual, Partner, Officer, Managing Member, or 5% or more Stockholder or Member) (Please Print) County, ss being first duly sworn, according to law, depose and say that the statements _____________________ (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) _______________ (Notary Expiration) NOTE: ALL DOCUMENTS BECOME PART OF THE PERMIT FILE AND WILL NOT BE RETURNED PAGE 2 American LegalNet, Inc. www.FormsWorkFlow.com