OREGON LIQUOR CONTROL COMMISSION ALCOHOL SERVER EDUCATION/LIQUOR LIABILITY INSURANCE EXEMPTION REQUEST Please Print or Type Name: _________________________________________________ Date of birth: ___/____/_____ mm dd yyyy Licensee name (if different than above): ________________________________________________ Trade Name (dba):_____________________________________________ License Type:________ Business Location Address: __________________________________________________________ City: ___________________________________________________ ZIP Code: ________________ This request form must be completed and signed by an OLCC licensee or license applicant. If the licensee or applicant is a corporation, limited liability company (LLC), or limited partnership, the application must be signed by a corporate officer or director (corporation), a member or managing member (LLC only) or a partner. I am requesting: (check all that apply) Exemption from alcohol server education requirements for an individual licensee or license applicant. In requesting this exemption, I hereby swear and affirm that: I will not engage in the sale or service of alcoholic beverages for consumption on OLCC-licensed premises, I will not directly manage or supervise persons who sell or serve alcohol for consumption on OLCC-licensed premises, and will not participate in establishing policies governing the sale or service of alcoholic beverages on any OLCC-licensed premises. I have a co-licensee or manager who meets this requirement. _______________________________________________________________________ (name of co-licensee or manager) (date of birth) Exemption from alcohol server education and liquor liability insurance requirements for a business licensed with an OLCC winery, brewery, or grower sales privilege license. In requesting this exemption, I hereby swear and affirm that the licensee(s) will not sell alcoholic beverages for consumption on the above-named premises, and will not allow the consumption of alcoholic beverages on the licensed premises. _______________ Initial here By initialing and signing this application, I swear all of the information on this application is true and correct, and I understand that under Oregon law (ORS 162.075) false swearing is a Class A misdemeanor. Applicant Signature: _______________________________________________ Date: __________ OLCC USE ONLY: Application Approved by_______________ Date _______ Denied License No. ____________ Premises No._________________ 9079 SE McLoughlin Blvd., Portland, OR 97222-7355 G PO Box 22297, Milwaukie, OR 97269-2297 Ph:(503) 872-5070 G www.oregon.gov/olcc (rev. 12/07) American LegalNet, Inc. www.FormsWorkflow.com