FOR OFFICE USE ONLY NEW PERMIT # TRANSFER REN 6606 Tussing Road, P.O. Box 4005, Reynoldsburg, Ohio 43068-9005 Telephone: (614) 644-3155 - http://www.com.ohio.gov/liqr Ohio Department of Commerce Division of Liquor Control SECTION A. Name of D4 Applicant: Permit Premises Address: Township (if outside city limits): LIST TOP FOUR OFFICERS: NAME CLUB OFFICERS STATEMENT DBA (doing business as): Federal Tax ID Number: City: Zip Code: County: OFFICE HELD RESIDENCE ADDRESS SSN DOB Affidavit Being first duly sworn according to law, depose and say: *The above-listed individuals are the current elected and controlling officers of the Club. *The Club was organized solely for and in the interest of the membership of a reputable organization, and not for the profit of any person, firm, or company, either directly or indirectly. *Only members in good standing can and are permitted to exercise the privileges of the Club. *The telephone number of the Club premises is *The Club was organized for: the purpose of: Fraternal Benevolent Social Charitable Recreational Political Regular Special meetings. Athletic Patriotic * Membership in the Club is subject to the consent and approval of the membership at * The yearly initiation fee is $ *The dues of $ are payable Weekly Monthly Quarterly Semi-Annually Yearly State of Ohio, I, (Please Print) elected and qualified as the County, ss being first duly sworn, according to law, deposes and says that he/she is duly (Office Held) of the (Club Name) (To be completed by Notary Public) Sworn to before me and subscribed in my presence this ______________day of _____________________________________, 20 _____________. ________________________________________ DLC4050 EOE/ADA SERVICE PROVIDER (Notary Public) _______________ (Notary Expiration) . (Signed) Rev. 9/13 FOR TTY USERS DIAL ORS 1-800-750-0750 American LegalNet, Inc. www.FormsWorkFlow.com