PLCB-3 2/12 COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD (ANSWER ALL QUESTIONS) APPLICATION FOR CLUB LIQUOR OR RETAIL DISPENSER LICENSE (SEE INSTRUCTIONS PAGE 2 OF 2 REVERSE) BUREAU OF LICENSING PAGE 1 OF 2 The undersigned organization hereby applies for the following type of License: PRIVATELY-OWNED PRIVATE GOLF COURSE CLUB LIQUOR (PGC) PRIVATELY-OWNED PRIVATE GOLF COURSE CATERING CLUB LIQUOR (GCC) 1. NAME OF APPLICANT ORGANIZATION 2. ADDRESS OF PREMISES (STREET, RURAL ROUTE, P.O. BOX NO.) (POST OFFICE) CLUB LIQUOR (C) CLUB RETAIL DISPENSER (G) CATERING CLUB LIQUOR (CC) (STATE) (ZIP) 3. NAME OF MUNICIPALITY 4. NAME OF OWNER OF PREMISES TYPE OF MUNICIPALITY CITY BORO TWP. INC. TOWN COUNTY PAGE NO./ INSTRUMENT NO. DEED BOOK VOLUME NO. 4(A). NAME OF OFFICERS, DIRECTORS, SHAREHOLDERS, PARTNERS OR MEMBERS OF PROPERTY OWNER. (ATTACH SEPARATE SHEET IF NECESSARY) TITLE 5. ADDRESS OF OWNER OF PREMISES LEASE EXPIRATION DATE 6. IS A CURRENT HEALTH LICENSE POSTED ON THE PREMISES? (CATERING CLUB ONLY) IF `YES', WHEN DOES IT EXPIRE? GIVE MONTH, DAY, YEAR. YES YES NO IF `YES', WHEN AND WHERE? 7. HAS THE APPLICANT PREVIOUSLY FILED AN APPLICATION FOR LICENSE? 8. PREMISES TO BE LICENSED NO LIST COMPLETE INFORMATION FOR EVERY ROOM WHICH IS TO BE USED IN THE OPERATION OF THE LICENSED BUSINESS, INCLUDING A SEPARATE KITCHEN, IF ANY, AND AREA TO BE USED FOR STORAGE OF ALCOHOLIC BEVERAGES. (ATTACH SEPARATE SHEET, IF NECESSARY.) ROOM WIDTH LENGTH LOCATED ON WHAT FLOOR SEATING CAPACITY DESIGNATED USE: SERVING, KITCHEN OR STORAGE 9. IS THE APPLICATION TO BE CONSIDERED FOR PRIOR APPROVAL? 10. IS THE APPLICATION TO BE CONSIDERED FOR NATIONAL VETERANS' ORGANIZATION? 11. THE PRIMARY INTEREST OR ACTIVITY OF THE CLUB IS 12. DATE CLUB ORGANIZED DATE AND PLACE INCORPORATED YES YES NO NO 13. IS A MANAGEMENT COMPANY EMPLOYED OR OTHERWISE CONTRACTED TO OPERATE, MANAGE OR OTHERWISE SUPERVISE ALL OR PART OF THE OPERATION? IF YES, LIST THE NAME AND ADDRESS OF THE ENTITY: YES NO 14. IS THE CLUB CHARTER IN POSSESSION OF THE ORIGINAL INCORPORATORS? IF `NO', IS IT IN THE POSSESSION OF THEIR DIRECT OR LEGITIMATE SUCCESSORS? YES YES NO NO N/A DO NOT WRITE BELOW THIS LINE CO/MNCP _ _ - _ _ _ ZIP _ _ _ _ _ - _ _ _ _ American LegalNet, Inc. www.FormsWorkFlow.com 15. TYPE OF PERMIT TO BE GRANTED RESOLUTION NEW LICENSE TRANSFER OF LICENSE 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 OF OFFICER/TITLE) (NAME OF OFFICER/TITLE) authorized to execute said application, and any other papers required by the Board. COMPLETE IN DETAIL QUESTIONS 16 THRU 19 - ATTACH SEPARATE SHEET, IF NECESSARY. 16. NAME OF OFFICERS & DIRECTORS OR TRUSTEES A. TITLE HOME ADDRESS DATE AND PLACE OF BIRTH U.S. CITIZEN? YES NO SALARY PAID BY CLUB NAME B. NAME C. NAME D. NAME E. NAME F. NAME 17. NAME OF STEWARD OR MANAGER OR RESPONSIBLE OFFICER NAME HOME ADDRESS DATE AND PLACE OF BIRTH U.S. CITIZEN? YES NO 18. NAME OF EMPLOYEE(S) A. POSITION HOME ADDRESS NAME B. NAME C. NAME D. NAME 19. TYPE OF MEMBERS ANNUAL DUES PER MEMBER NUMBER OF MEMBERS ACTIVE SOCIAL OTHER $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com PLCB-3 2/12 COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD APPLICATION FOR CLUB LIQUOR OR RETAIL DISPENSER LICENSE (SEE INSTRUCTIONS ON REVERSE) BUREAU OF LICENSING PAGE 2 OF 2 20. CONVICTION RECORD: The following is a record of all felony and misdemeanor convictions of the individual owner, all partners, the manager and all corporate officers, directors and stockholders. (Attach separate sheet, if necessary.) If there have been no such convictions, check here: No such convictions NAME DATE OF CONVICTION CHARGE DISPOSITION LOCATION OF COURT (COUNTY AND STATE) 21. 22. 23. Do any officers, directors, agents or employees of the club hold any license issued by this Board? Are any officers, directors, agents or employees of the club also employees of this Board or of any licensee? YES YES NO NO Does the applicant or any officer, director, stockholder, agent or employee have any financial interest, either directly or indirectly, in any other class of license or permit issued by this Board, or in the ownership, leasehold, or equipment, of any property used by such other licensee or permittee, or mortgage lien against the same, or have they loaned any money, or given credit, or anything of value, for equipping, maintaining or conducting an establishment used in such other license or permit? YES NO 24. Will any person having any financial interest as an individual, or as an officer, director, stockholder, agent or employee in another class of license or permit issued by this Board be in any manner interested, either directly or indirectly, in the business proposed to be licensed under this application, or in the ownership or leasehold of the property or equipment to be used in the operation of the said business, or any mortgage lien against the same, or have they loaned any money, or given credit, or anything of value, to the applicant, or any officer, director, stockholder, servant, agent or employee of said applicant, for equipping, maintaining or conducting this business? NO YES IF A `YES' RESPONSE IS GIVEN TO QUESTIONS 21, 22, 23 OR 24, ATTACH SEPARATE SHEET, WITH DETAILS. 25. A placard, PLCB-1296, Public Notice of Application Alcoholic Beverages, was posted on (DATE) _____________ in a conspicuous place on the outside of the premises as required by the Liquor Code and Regulations of the Board, and will remain posted until a notice of approval or refusal is received by the applicant. I swear or affirm, subject to the penalties provided by 18 Pa. C.S. §4904 and 47 P.S. §4-403 (h) and/or §4-436 (j), 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 TITLE HOME ADDRESS PHONE PHONE PREMISES PHONE NO. DATE SIGNED E-MAIL ADDRESS. American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS The Application for Club Liquor or Retail Dispenser License is to be submitted to apply for a new club license OR to apply for the transfer of an existing club license. All questions must be answered. All attached