PLCB-706 3/06 I COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD APPLICATION FOR APPROVAL OF APPOINTMENT OF MANAGER BUREAU OF LICENSING (SEE INSTRUCTIONS ON REVERSE) Approval is requested for the appointment of a PERMANENT TEMPORARY Manager for the following licensee: 1. NAME LID NO. 2. TRADE NAME (IF ANY) LICENSE NO. 3. ADDRESS OF PREMISES (STREET, RURAL ROUTE, P.O. BOX NO.) 4. DO YOU HOLD ANY OTHER LICENSE ISSUED BY THIS BOARD? (POST OFFICE) YES (STATE) (ZIP) NO IF “YES,” GIVE LICENSE NO.(S) INFORMATION CONCERNING PROPOSED MANAGER: (An individual licensee may designate himself as manager) 5. NAME 6. HOME ADDRESS (STREET, RURAL ROUTE, P.O. BOX NO.) (POST OFFICE) (STATE) (ZIP) 7. PRIOR RESIDENCE : LIST RESIDENCE FOR FIVE YEARS IF YOU HAVE NOT RESIDED AT THE ABOVE-LISTED HOME ADDRESS FOR THAT PERIOD. FROM TO STREET, RURAL ROUTE, P.O. BOX NO. 8. DATE AND PLACE OF BIRTH POST OFFICE U.S. CITIZEN? YES STATE ZIP IF NATURALIZED, GIVE DATE AND PLACE NO 9. STATE PRESENT EMPLOYMENT OR OTHER BUSINESS ARE YOU OR HAVE YOU EVER BEEN A LICENSEE? YES 10. ARE YOU OR HAVE YOU EVER BEEN EMPLOYED BY ANOTHER LICENSEE? YES NO NO IF “YES,” WHEN AND IN WHAT CAPACITY? 11. CONVICTION RECORD: The following is a record of all felony and misdemeanor convictions of the proposed manager. (Attach separate sheet, if necessary.) If there have been no such convictions, check here: DATE OF CONVICTION NAME CHARGE No such convictions DISPOSITION LOCATION OF COURT (COUNTY AND STATE) FOR TEMPORARY MANAGER ONLY 12. APPOINTMENT DATE FROM 13. REASON FOR APPOINTMENT TO RESOLUTION (CORPORATIONS, LIMITED LIABILITY COMPANIES AND LIMITED PARTNERSHIPS ONLY) At a regular or special meeting held on ____________________________________ , 20 _______ by the applicant, it was resolved that said application be filed with the Pennsylvania Liquor Control Board, and that _________________________________________ and/or _______________________________________ is/are hereby (NAME/TITLE) (NAME/TITLE) authorized to execute said application, and any other papers required by the Board. DO NOT WRITE BELOW THIS LINE American LegalNet, Inc. www.FormsWorkflow.com 14. FOR LIMITED WINERY APPLICANTS ONLY Is the appointment of manager for an additional Board-Approved Location? YES NO If “Yes,” list the location: If “Yes,” is/are other licensed limited winery(ies) operated in conjunction with the above listed Board-Approved location? If “Yes,” will the proposed manager act as manager for each limited winery(ies)? YES YES NO NO If “Yes,” list license number(s), LID(s) and licensee(s) name: 15. Is the proposed manager: YES A B C Member, partner, officer, director, stockholder or creditor of any other licensee? Owner, proprietor or lessor of any place licensed by this Board? NO YES D E Holder of any license issued by this Board? G 16. Is a management company employed? Employee of any licensee? F Financially interested, either directly or indirectly, in the profits of any business licensed by this Board? If “Yes,” explain: Employee of the Pennsylvania Liquor Control Board? YES NO YES If “Yes,” was it reported to the PLCB? NO Public official enforcing penal laws, either by appointment or election? NO List name of management company I swear or affirm, subject to the penalties provided by 18 Pa. C.S. §4904 47 P.S. §4-403(h) and/or §4-436(j) and/or §5-504(b) and/or §7-7-704, that the foregoing answers and statements provided herein are true and complete to the best of my knowledge and belief. SIGNATURE TITLE NAME OF ATTORNEY REPRESENTING YOU IN THIS MATTER, IF ANY HOME ADDRESS PHONE ADDRESS ( SIGNATURE HOME ADDRESS ) TITLE PHONE PHONE ( ( ) DATE SIGNED ) INSTRUCTIONS This form is for the appointment of a permanent manager, for a change of the permanent manager, or for the temporary appointment of a manager. Limited Liability Companies, Limited Partnerships and Corporations, except clubs, should use this form to report a change in manager only. If there have been other business structure changes in addition to the change of the manager, complete form PLCB-866, Notice of Change in the Business Structure of Licensed Corporations, Limited Liability Companies or Limited Partnerships, Except Clubs to report those changes. 1. A fee of $135.00 is required for any individual not currently Board-approved on this license. If the proposed manager is currently a member, partner or officer of this license, a fee of only $60.00 is required. Fee made payable to “PLCB” or “Commonwealth of Pennsylvania” MUST accompany this form. A fee submitted from out-of-state must be in the form of a certified check or money order. 2. One photograph of the manager, 1½" x 1½" in size, taken within one year and the name of the person, license number and the name and address of the premise must appear on the reverse of each photograph, MUST accompany this form. The photograph must have a matte finish. 3. A Request for Criminal Record Check, Form PLCB-2018, MUST be submitted for the proposed manager with a $10.00 remittance. This form is not required for a current Board-approved member, partner or officer UNLESS the individual was approved more than two years prior to submitting this application. 4. PLCB-1773, Appendix Social Security Information MUST be submitted listing the social security number of the proposed manager. 5. If a current member, partner or officer of licensee is named as manager and holds no other employment, submit an affidavit attesting the applicant Manager is available to devote full time to the operation of the premises and has no other employment. IF YOU REQUIRE ASSISTANCE IN COMPLETING THE APPLICATION PACKET, CALL THE LICENSING INFORMATION CENTER AT (717) 783-8250, OPTION #7. American LegalNet, Inc. www.FormsWorkflow.com