CORPORATION QUESTIONNAIRE FORM INSTRUCTIONS Authority to do Business in Oregon Your corporation must be approved by the Oregon Secretary of State’s office to do business in Oregon. List Corporate Officers List the President; any Vice President with responsibility over the operation of the business; Secretary; and Treasurer List Board of Directors List each Director who owns or controls 3% or more of the voting stock List Stockholders If there are 20 or more stockholders, only those owning or controlling 10% or more of the issued stock need to be listed. You may include the information on a separate sheet. List the number (not percentage) of shares held by each stockholder. In the box labeled “Number of Stock Shares:” list the total number of shares issued, the total number of unissued shares, and the total shares the corporation is authorized to issue. If a stockholder that owns or controls 10% or more of the issued stock is a legal entity, like another corporation or limited liability company (LLC), that legal entity must also complete its own separate questionnaire. Server Education Designee If you are applying for a liquor license that allows customers to drink alcohol at the business you must list a person to take an OLCC-approved Alcohol Server Education class for the corporation. This person must have the authority to set standards and policies for alcohol servers at your business. Officer’s Signature The form must be signed by one of the corporate officers listed on this form. CQ Instructions (08/11) OREGON LIQUOR CONTROL COMMISSION CORPORATION QUESTIONNAIRE Please Print or Type Corporation Name:__________________________________________ Year Incorporated:________ Trade Name (dba):__________________________________________________________________ Business Location Address:___________________________________________________________ City:________________________________________________________ List Corporate Officers: ZIP Code: ___________ ___________________________________________ (name) ___________________________________________ ______________________________________________ (title) ______________________________________________ ___________________________________________ ______________________________________________ ___________________________________________ ______________________________________________ List Board of Directors: __________________________________________________________________________________ (name) __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ List Stockholders: (Note: If any stockholder is another legal entity, that entity may also need to complete another Corporation Questionnaire. See Liquor License Application Guide for more information.) Stockholders: Number of Shares Held: ________________________________ ___________ ________________________________ ___________ Issued:________________ ________________________________ ___________ Unissued:______________ _________________________________ ___________ Number of Stock Shares: Total Shares Authorized to Issue:_______________ Server Education Designee:____________________________ DOB: _______________________ (See Liquor License Application Guide for more information) I understand that if my answers are not true and complete, the OLCC may deny my license application. Officer’s Signature:___________________________________________________ Date:________ (name) (title) 1-800-452-OLCC (6522) www.oregon.gov/olcc (rev. )