pLCB-35 2/12 CoMMoNWeaLTh of peNNSYLvaNIa pennsylvania liquor control board application for distributor or importing distributor license (see instructions paGe 2 oF 2 reverse) BUReaU of LICeNSINg page 1 of 2 The undersigned hereby applies for a for a the term ending 1. 2. 3. NaMe 0f appLICaNT TRaDe NaMe (If aNY) aDDReSS of pReMISeS (STReeT, RURaL RoUTe, p.o. BoX No.) NeW TRaNSfeR of a DISTRIBUToR DISTRIBUToR IMpoRTINg DISTRIBUToR LICeNSe, oR IMpoRTINg DISTRIBUToR LICeNSe, for . . If for transfer, give license number (poST offICe) (STaTe) (ZIp) 4. NaMe of MUNICIpaLITY TYpe of MUNICIpaLITY CITY 5. 6. WILL YoU SeLL MaLT/BReWeD BeveRageS oN SUNDaY? CoMpLeTe IN DeTaIL - aTTaCh SepaRaTe SheeT, If NeCeSSaRY. BoRo No TWp. CoUNTY INC. ToWN YeS NaMe of INDIvIDUaL appLICaNT, paRTNeRS, MeMBeRS, oR offICeRS & DIReCToRS a. NaMe TITLe hoMe aDDReSS DaTe aND pLaCe of BIRTh LeNgTh of U.S. ReSIDeNCe CITIZeN? IN pa. YRS. MThS. YeS No B. NaMe C. NaMe D. NaMe 7. The foLLoWINg IS a LIST of aLL pLaCeS To Be USeD IN The opeRaTIoN of The BUSINeSS: (If oNLY a poRTIoN of The pReMISeS IS To Be LICeNSeD, gIve DeTaILS UNDeR "LoCaTIoN"). pURpoSe NaMe of oWNeR of pReMISeS foR WhICh LoCaTIoN pReMISeS WILL Be USeD aDDReSS of oWNeR of pReMSIeS LeaSe eXpiration date NaMe aND TITLe of offICeRS, DIReCToRS, ShaRehoLDeRS, paRTNeRS, oR MeMBeRS of pRopeRTY oWNeRS (aTTaCh a SepaRaTe SheeT If NeCeSSaRY) a. dEEd BOOK vOl. nO. B. dEEd BOOK vOl. nO. C. dEEd BOOK vOl. nO. 8. PAGE nO./INSTRUMeNT No. LoCaTIoN PAGE nO./INSTRUMeNT No. PAGE nO./INSTRUMeNT No. STaTe oTheR eMpLoYMeNT oR BUSINeSS 9. Do YoU INTeND To SeLL aNY ITeMS oTheR ThaN MaLT oR BReWeD BeveRageS? LIST ITeMS - aTTaCh SepaRaTe SheeT, If NeCeSSaRY. YeS No do not Write beloW tHis line Co/MNCp _ _ - _ _ _ ZIp _ _ _ _ _ - _ _ _ _ American LegalNet, Inc. www.FormsWorkFlow.com 10. resolution (corporations and limited liabilitY companies 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 (NaMe/TITLe) (NaMe/TITLe) hereby authorized to execute said application, and any other papers required by the Board. 11. foR CoRpoRaTIoNS aND LLCs oNLY (a) DeSCRIpTIoN: RegISTeReD NaMe INCoRpoRaTeD/oRgaNIZeD DaTe pLaCe iF ForeiGn corporation Give date oF certiFicate oF autHority or iF ForeiGn llc Give date reGistered in pa 12. foR CoRpoRaTIoNS oNLY (a) NUMBeR of ShaReS of SToCK ISSUeD: CoMMoN pRefeRReD ToTaL (B) LIST aLL SToCKhoLDeRS - aTTaCh SepaRaTe SheeT, If NeCeSSaRY. NaMe of SToCKhoLDeR 1) NaMe hoMe aDDReSS DaTe aND pLaCe of BIRTh LeNgTh of U.S. ReSIDeNCe citiZen? IN pa. YRS. MThS. YeS No KIND aND aMount oF stocK Held 2) NaMe 3) NaMe 4) NaMe 5) NaMe 13. NaMe of MaNageR hoMe aDDReSS DaTe & pLaCe of BIRTh U.S. citiZen? YeS No 14. CoNvICTIoN ReCoRD: The following is a record of all felony and misdemeanor convictions of the individual owner, all partners, all members, 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) 15. Is a management company employed or otherwise contracted to operate, manage or otherwise supervise all or part of the operation? YeS No If yes, list the name and address of the entity: American LegalNet, Inc. www.FormsWorkFlow.com pLCB-35 2/12 CoMMoNWeaLTh of peNNSYLvaNIa peNNSYLvaNIa LIqUoR CoNTRoL BoaRD application for distributor or importing distributor license (See INSTRUCTIoNS oN ReveRSe) BUReaU of LICeNSINg page 2 of 2 16. 17. application to be considered for prior approval? Has the applicant previously filed an application for license or held a license issued by this Board? If `yes', when and where? YeS YeS No No 18. Neither the applicant nor any member, officer, director, stockholder, agent or employee has any financial interest, either directly or indirectly, in any other 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, nor has the applicant loaned any money, or given credit, or anything of value, for equipping, maintaining or conducting an establishment used in such other license or permit, except as follows: If there are no exceptions, check here: 19. No exception No person having any financial interest as an individual, or as a member, officer, director, stockholder, agent or employee in another license or permit issued by this Board will 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, nor has he loaned any money, or given credit, or anything of value, to the applicant, or any member, officer, director, stockholder, servant, agent or employee of said applicant, for equipping, maintaining or conducting this business, except as follows: If there are no exceptions, check here: 20. No exception None of the applicants hold any public office involving the enforcement of penal laws, or penal ordinances or resolutions, except as follows: If there are no exceptions, check here: 21. No exception a placard, pLCB-1296, public Notice of application alcoholic Beverages, was posted on (DaTe)________________________ in a conspicuous place on the outside of the premises for which the license is applied, as required by the Liquor Code and the Regulations of the Board, and will remain posted until the license or a notice of refusal of the application is received by the applicant. I swear or affirm, subject to the penalties provided by 18 Pa. C.S. §4904, and 47 P.S. §4-436(j), that the foregoing answers and statements provided herein are true and complete to the best of my knowledge and belief. SIgNaTURe hoMe aDDReSS TITLe phoNe NaMe of aTToRNeY RepReSeNTINg YoU IN ThIS MaTTeR, If aNY phoNe aDDReSS SIgNaTURe TITLe DaTe SIgNeD hoMe aDDReSS phoNe pReMISeS phoNe No. e-MaIL aDDReSS American LegalNet, Inc. www.FormsWorkFlow.com instructions This form is to be submitted as part of the application packet to apply for a new Distributor or Importing Distributor License, or to apply for the transfer of an existing Distributor or Importing Distributor License. all questions must be answered. all attac