APPLICATION FOR LICENSE DISTILLERY CERTIFICATE BROKER PERMIT PLCB-482 5/05 COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD BUREAU OF LICENSING PAGE 1 OF 2 The undersigned hereby applies for a Distillery Certificate Broker Permit to expire December 31, 20 _________________ , as a _____________________________________________________________________________________________ . (INDIVIDUAL, PARTNERSHIP, LIMITED LIABILITY COMPANY, OR CORPORATION) 11. COMPLETE IN DETAIL - ATTACH SEPARATE SHEET, IF NECESSARY. NAME OF INDIVIDUAL APPLICANT, MEMBERS, PARTNERS, OR OFFICERS & DIRECTORS TITLE DATE AND PLACE OF BIRTH HOME ADDRESS U.S. CITIZEN? NO YES A. NAME B. NAME C. NAME D. NAME 12. U.S. CITIZEN? NAME OF MANAGER HOME ADDRESS DATE & PLACE OF BIRTH YES NO 13. 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) DO NOT WRITE BELOW THIS LINE American LegalNet, Inc. www.FormsWorkflow.com 4. FOR CORPORATIONS AND LIMITED LIABILITY COMPANIES ONLY INCORPORATED/ORGANIZED A. REGISTERED NAME PLACE 4B. IF FOREIGN CORPORATION GIVE DATE OF CERTIFICATE OF AUTHORITY OR IF FOREIGN LLC GIVE DATE REGISTERED IN PA DATE RESOLUTION At a regular or special meeting held on _________________________________________ , 20 ______ by the applicant corporation, 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. 5. FOR CORPORATIONS ONLY – List all stockholders (attach separate sheet, if necessary). NAME OF STOCKHOLDER HOME ADDRESS DATE & PLACE OF BIRTH U.S. CITIZEN? YES NO KIND AND AMOUNT OF STOCK HELD 1) NAME 2) NAME 3) NAME 4) NAME 5) NAME 6) NAME 7) NAME 16. Address of Pennsylvania Office 17. Address of Principal Office if outside Pennsylvania 18. Address of all other offices 19. Applicant has been dealing in Distillery Bonded Warehouse Certificates for years, ________________ and is registered or licensed to deal in such certificates in the following states: American LegalNet, Inc. www.FormsWorkflow.com PLCB-482 5/05 APPLICATION FOR LICENSE DISTILLERY CERTIFICATE BROKER PERMIT COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD BUREAU OF LICENSING (SEE INSTRUCTIONS ON REVERSE) PAGE 2 OF 2 10. Neither the applicant nor any member officer, director, partner or stockholder has been refused a license or registration in any other state or had a license or registration for the handling of Distillery Bonded Warehouse Certificates or other securities revoked except as follows: If there are no exceptions, check here: No Exceptions 11. The following is a record of the business or employment of the applicant, all partners, all members, or all officers, directors and stockholders, if a corporation or LLC during the past five years: 12. The following is a detailed description of applicant’s plan of business in dealing in Distillery Bonded Warehouse Certificates. 13. Neither the applicant nor any member, officer, director or stockholder has ever failed in business, made a compromise with creditors, taken advantage of the Bankruptcy Act, or the exemption law, or pleaded the Statute of Limitations, except as follows (Give dates, whether honorably discharged and all particulars): If there are no exceptions, check here: No Exceptions 14. There is attached a statement of the financial condition of the applicant as of the close of the preceding month, showing assets and liabilities in detail. I swear or affirm, subject to the penalties provided by 18 Pa. C.S. §4904 and 47 P.S. §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 ) American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS This form is to be submitted to apply for a new Distillery Certificate Broker Permit. All questions must be answered. All attached sheets must include the applicant’s name and address. Fees and documents to be submitted with this application include: 1. PLCB-1773, Appendix Social Security Information MUST be submitted showing the social security number(s), name(s), and title(s) of each individual applicant, partner, manager, member and each officer, director and stockholder. 2. A filing fee of $700.00 and a permit fee of $175.00 MUST accompany the application. Make remittances payable to “PLCB” or “Commonwealth of PA.” INFORMATION DO NOT SUBMIT ANY OTHER DOCUMENT WITH THIS APPLICATION PACKET. SHOULD YOU BE REQUIRED TO SUBMIT SUCH DOCUMENTATION, OTHER THAN FOR THE INVESTIGATIVE OFFICER’S REVIEW, YOU WILL BE NOTIFIED IN WRITING. FOR THE INVESTIGATIVE OFFICER’S REVIEW, YOU SHOULD HAVE AVAILABLE COPIES OF LITERATURE, IF ANY WILL BE USED, SOURCES OF SUPPLY, PROSPECTIVE PURCHASES RATE OF COMMISSION, OR POSSIBLE PROFIT, ETC. THE PERMIT MAY NOT BE ASSIGNED OR TRANSFERRED AND SHALL BE CONSPICUOUSLY DISPLAYED AT THE PLACE OF BUSINESS OF PERMITTEE. IF YOU REQUIRE ASSISTANCE IN COMPLETING THE APPLICATION PACKET, CALL THE LICENSING INFORMATION CENTER AT (717) 783-8250, OPTION #7. 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