OHIO DEPARTMENT OF COMMERCE - DIVISION OF LIQUOR CONTROL 6606 Tussing Road Reynoldsburg, Ohio 43068-9005 Telephone No. (614) 644-2431 http://www.com.ohio.gov/liqr APPLICATION FOR I PERMIT PERMIT FEE $200.00 APPLICATION PROCESSING FEE - $100.00 § 4303.23 I permit. Permit I may be issued to wholesale druggists to purchase alcohol from the holders of A-3 permits and to import alcohol into this state subject to terms imposed by the division of liquor control; to sell at wholesale to physicians, dentists, druggists, veterinary surgeons, manufacturers, hospitals, infirmaries, and medical or educational institutions using such alcohol for medicinal, mechanical, chemical, or scientific purposes, and to holders of G permits for nonbeverage purposes only; and to sell alcohol at retail in total quantities at each sale of not more than one quart, 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. The sale of alcohol under this section is subject to section 4303.34 of the Revised Code. The fee for this permit is two hundred dollars. "Wholesale druggists," as used in this section, includes all persons holding federal wholesale liquor dealers' licenses and who are engaged in the sale of medicinal drugs, proprietary medicines, and surgical and medical appliances and apparatus, at wholesale. (eff. 6-26-03) TYPE OR PRINT PLAINLY Name of Wholesale Druggist: Business Address: City: Mailing Address: City: Residence Address: City: List Federal Wholesale Liquor Dealer's License Number: State: Zip Code: Township (if outside city limits): State: Zip Code: County: State: Zip Code: Address: Attorney's Name: City, State, & Zip: Phone # ANSWER ALL QUESTIONS ON PAGE TWO FOR DIVISION USE ONLY Coder: Taxing District Permit Number Receipt # Remarks: Reviewer Action: DLC4148 EOE/ADA SERVICE PROVIDER Page 1 FOR TTY USERS DIAL ORS 1-800-750-0750 Rev. 10/2010 American LegalNet, Inc. www.FormsWorkFlow.com 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. 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 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. Your permit certificate is issued for a permit period that expires on October1st, 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. 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) (City) (State) (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 _____________. ________________________________________ _______________ NOTE: ALL DOCUMENTS BECOME PART OF THE PERMIT FILE AND WILL NOT BE RETURNED PAGE 2 American LegalNet, Inc. www.FormsWorkFlow.com