LIMITED LIABILITY COMPANY (LLC) QUESTIONNAIRE FORM INSTRUCTIONS Authority to do Business in Oregon x Your LLC must be approved by the Oregon Secretary of State’s office to do business in Oregon. List Members of LLC x x x x List all Managing Members If there are 20 or more members, only those owning or controlling 10% or more of the membership need to be listed. You may include the information on a separate sheet. List the percentage of membership held by each member. If a member that owns or controls 10% or more of the membership is a legal entity, like a corporation or another LLC, that legal entity must also complete its own separate questionnaire. Server Education Designee x 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 x The form must be signed by a Managing Member listed on this form. LLC Questionnaire Instructions (08/11) OREGON LIQUOR CONTROL COMMISSION LIMITED LIABILITY COMPANY QUESTIONNAIRE Please Print or Type LLC Name:________________________________________________ Year Filed:_______________ Trade Name (dba):___________________________________________________________________ Business Location Address:____________________________________________________________ City:______________________________________________________ ZIP Code:_______________ List Members of LLC: Percentage of Membership Interest: 1. ____________________________________ _______________________________ (managing member) 2. ____________________________________ _______________________________ (members) 3. ____________________________________ _______________________________ 4. ____________________________________ _______________________________ 5. ____________________________________ _______________________________ 6. ____________________________________ _______________________________ (Note: If any LLC member is another legal entity, that entity must also complete an LLC, Limited Partnership or Corporation Questionnaire. If the LLC has officers, please list them on a separate sheet of paper with their titles.) Server Education Designee:__________________________________ DOB: __________________ I understand that if my answers are not true and complete, the OLCC may deny my license application. Signature:_____________________________________________________ Date:_______________ (name) (title) 1-800-452-OLCC (6522) www.olcc.state.or.us (rev. 8/11)