PLCB-1773 4/05 COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD APPENDIX SOCIAL SECURITY INFORMATION BUREAU OF LICENSING Pennsylvania Right To Know Act [65 P.S. §66.1-66.4] restricts dissemination of Social Security Account Numbers. The identifying information contained on this form is not considered public information. This is not a public document. In accordance with the Federal Privacy Act of 1974, you have the right to refuse to disclose your Social Security Account Number. Such refusal will not result in a denial of any right, benefit, or privilege provided by law. Your Social Security Account Number will be used for crossreference identification within the Liquor Control Board and among other state agencies. The Liquor Control Board is empowered by the Pennsylvania Liquor Code (47 P.S. §1-101, et seq.), to request your Social Security Account Number. This form must be filed whether or not social security numbers are disclosed. 1. NAME OF LICENSEE 2. TRADE NAME (IF ANY) 3. ADDRESS OF PREMISES (STREET, RURAL ROUTE, P.O. BOX NO.) (POST OFFICE) LICENSE NO. LID NO. (STATE) (ZIP) 4. THE NAMES LISTED HERE MUST AGREE WITH THE INFORMATION LISTED ON THE APPLICATION FOR LICENSE OR PERMIT. COMPLETE IN DETAIL - ATTACH SEPARATE SHEET, IF NECESSARY. SOCIAL SECURITY NUMBER LAST A B C D E F G H I J NAMES OF ALL MEMBERS, OFFICERS, DIRECTORS, STOCK-HOLDERS, MANAGER, STEWARD, LICENSEE OR PARTNER/PARTNERSHIP FIRST MIDDLE INITIAL NAME OF PERSON SIGNING NAME OF PERSON SIGNING SIGNATURE TITLE SIGNATURE TITLE HOME ADDRESS PHONE HOME ADDRESS PHONE ( DATE SIGNED ) DATE SIGNED ( ) American LegalNet, Inc. www.USCourtForms.com