PLCB-959 5/08 COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD PENNSYLVANIA APPLICATION FOR CORRECTION TO LICENSE OR PERMIT BUREAU OF LICENSING (SEE INSTRUCTIONS ON REVERSE) The undersigned requests a corrected license or permit be issued in accordance with the information shown in Questions 5-8, subject to, and in compliance with the provisions of the Liquor Code and Regulations of the Board, including those provisions pertaining to the licensee being the only person having a pecuniary interest in the licensed business. This application is made for the License term expiring , . INFORMATION AS IT APPEARS ON PRESENT LICENSE OR PERMIT 1. NAME LICENSE OR PERMIT NO. EXTENDED HOURS FOOD LICENSE YES 2. TRADE NAME (IF ANY) AMUSEMENT PERMIT YES (STREET, RURAL ROUTE, P.O. BOX NO.) 3. ADDRESS OF PREMISES 4. NAME OF MUNICIPALITY (POST OFFICE) TYPE OF MUNICIPALITY CITY BORO TWP. NO (STATE) INC. TOWN NO SUNDAY SALES PERMIT YES NO (ZIP) COUNTY INFORMATION AS IT IS TO APPEAR ON CORRECTED LICENSE OR PERMIT 6. TRADE NAME (IF ANY) 5. NAME OF LICENSEE OR PERMITTEE 7. ADDRESS OF PREMISES (STREET, RURAL ROUTE, P.O. BOX NO.) TYPE OF MUNICIPALITY 8. NAME OF MUNICIPALITY CITY 9. (POST OFFICE) BORO TWP. (STATE) INC. TOWN (ZIP) COUNTY RESOLUTION (CORPORATIONS AND CLUBS ONLY) At a regular or special meeting held on , by the applicant corporation/club, it was resolved that said application be filed with the Pennsylvania Liquor Control Board, and that and/or is/are (NAME OF OFFICER/TITLE) (NAME OF OFFICER/TITLE) hereby authorized to execute said application, and any other papers required by the Board. 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) and/or §5-504(b) and/or §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 TITLE HOME ADDRESS PHONE PHONE DATE SIGNED DO NOT WRITE BELOW THIS LINE American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS This form is to be used by all licensees and permittees, when there is a change to the name, trade name, or address of the licensed establishment, provided there is no change in the ownership of the business or actual principal location of the licensed premises. The change to licensee name could be a deletion of a partner, either by voluntary retirement or death. If a partner is being added or the ownership is to be changed, or the principal location of the premises is to be changed, an application packet for transfer of license must be submitted. 1. A fee of $45.00 MUST accompany this application, unless the change is ONLY to the mailing address of the licensed premises. Make remittance payable to “PLCB” or Commonwealth of Pennsylvania”. 2. The application MUST be signed by all partners appearing on the license as shown on Question 1. Complete information must appear on the form. In the case of death of a partner the application must be signed for the deceased partner by the Administrator or Executor of the estate. A short form certificate from the Registrar of Wills MUST accompany this application. An exception is granted only in cases where the license is issued in the name of husband and wife. If letters of administration are not deemed necessary, the application may be signed only by the surviving spouse; however, documentary evidence of death must then be submitted. In the case of a change to the mailing address, submit a copy of the Post Office’s notice of change unless you were notified by the Pennsylvania Liquor Control Board to submit the application. The address reported must be of the licensed premises. It may not be a forwarding address. IF YOU REQUIRE ASSISTANCE IN COMPLETING THE APPLICATION PACKET, CALL THE LICENSING INFORMATION CENTER AT (717) 783-8250. SEND THE APPLICATION PACKET TO: PENNSYLVANIA LIQUOR CONTROL BOARD, BUREAU OF LICENSING, P.O. BOX 8940, HARRISBURG, PA 17105-8940. American LegalNet, Inc. www.FormsWorkflow.com