OREGON LIQUOR CONTROL COMMISSION CHANGE OF INFORMATION APPLICATION Please Print or Type Use this application to request a duplicate license certificate, change of trade name, change of licensee name, change to legal entity and/or deletion of partner(s). Remember to attach all requested documents. Section 1: Complete This Section For All Requests 1. Licensee Name(s):____________________________________________________________ (as currently licensed) ___________________________________________________________________________ 2. Trade Name (dba):________________________________ Type of License:_______________ (current business name) (O, L, F, etc.) 3. Business Address:____________________________________________________________ (street) (city) (ZIP code) 4. Mailing Address:______________________________________________________________ (street) (city) 5. Telephone Number:____________________________ (business) (ZIP code) ___________________________ (home) 6. Check here for a duplicate license certificate Section 2: Change of Trade Name New Trade Name (dba):________________________________________________________ Section 3: 1. New Name:__________________________________________________________________ Change of Legal 2. Date of Name Change:___________________ Name 3. Attach a signed copy of legal document(s). Section 4: 1. Entity Name:__________________________________________________________________ Change to Legal 2. Complete and attach LLC or Corporation Questionnaire. Entity (Corp. or LLC) 3. Attach a signed copy of modified lease agreement if applicable. Section 5: Deletion of Partner(s) 1. Name of Deleted Partner(s):_____________________________________________________ __________________________________________________ ___ 2. Attach a copy of the legal document(s) or letter of resignation, signed by the deleted partner(s), showing the partner(s) will no longer have an interest in the business. If deleted partner(s) appear on the lease, you must attach a copy of a modified lease agreement. I understand that if my answers are not true and complete, the OLCC may deny my license application. Licensee Name:___________________________________ Title:______________________________ Licensee Signature:______________________________________ Date:_____________________ 1-800-452-OLCC (6522) www.oregon.gov/olcc (rev. 12/07) American LegalNet, Inc. www.FormsWorkflow.com