PLCB-193 6/07 COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD AFFIDAVIT OF COMPLIANCE BUREAU OF LICENSING REGARDING NOTICE POSTING AS REQUIRED BY PENNSYLVANIA LIQUOR CODE AND BOARD REGULATIONS License Number ___________________ LID #: ______________ Applicant ________________________________________ Address of Premises ________________________________________ ________________________________________ (ZIP CODE) Type of Application: New with an Amusement Permit New without an Amusement Permit Extension Transfer with an Amusement Permit Transfer without an Amusement Permit Change of Officers The undersigned applicant for a license action concerning alcoholic beverages, _____________ _______________________________________________________________ , swears or affirms that a “Public Notice of Application” has been and will be continuously and conspicuously posted on the premises for which the license action is applied, in the manner prescribed by the Liquor Code and Board Regulations, from the date the application was filed with the Board, ___________________ . (INSERT DATE) (SIGNATURE) (SIGNATURE) (SIGNATURE) The foregoing statements are provided under penalty of perjury, 18 Pa. C.S.A. §4903 and §4904, and 47 P.S. §4-403(h) and/or §4-436(j). This affidavit must be submitted in conjunction with each new, transfer, or extension application and any notice of change in officers or stockholders constituting a change of corporate control. New and transfer applications for retail licenses, except clubs, performing arts and public venues, must indicate if the transaction includes an amusement permit. The “Public Notice of Application” must be posted on the date the application or notice is filed and must remain posted until the application has been approved or refused by the Board. This affidavit must be executed by the same person or persons who signed the application or notice. If the applicant is a corporation, the corporate officer(s) who signed the application of notice shall execute this affidavit by affixing the same signature(s) and title(s) hereon. If the applicant is a limited liability company, the member(s) who signed the application of notice shall execute this affidavit by affixing the same signature(s) hereon. NOTE: If the transfer of controlling interest in a corporation affects more than one license, EACH LICENSED PREMISES must be properly posted. List additional license numbers here: _______________________________________________ American LegalNet, Inc. www.FormsWorkflow.com