APPLICATION FOR LICENSE MANUFACTURE, STORAGE OR TRANSPORTATION PLCB-1350 02/08 COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD BUREAU OF LICENSING (SEE INSTRUCTIONS PAGE 2 OF 2 REVERSE) The undersigned hereby applies for PAGE 1 OF 2 (ALTERNATING BREWER, BREWERY, DISTILLERY, DISTILLERY OF HISTORICAL SIGNIFICANCE, WINERY, LIMITED WINERY, BONDED WAREHOUSE, BAILEE FOR HIRE, TRANSPORTER-FOR-HIRE (CLASS A), (CLASS B) OR (CLASS C) License for the license period ending December 31, _______________ . 11. NAME OF APPLICANT LICENSE/PERMIT NO. 12. TRADE NAME (IF ANY) LID NO. 13. ADDRESS OF PREMISES (STREET, RURAL ROUTE, P.O. BOX NO.) 4. NAME OF MUNICIPALITY TYPE OF MUNICIPALITY CITY (POST OFFICE) BORO TWP. INC. TOWN (STATE) (ZIP) COUNTY 15. COMPLETE IN DETAIL - ATTACH SEPARATE SHEET, IF NECESSARY. NAME OF INDIVIDUAL APPLICANT, MEMBERS, PARTNERS, OR OFFICERS & DIRECTORS TITLE HOME ADDRESS DATE AND PLACE OF BIRTH U.S. CITIZEN? YES NO (A) NAME (B) NAME (C) NAME (D) NAME 6. LIST ALL PLACES IN PENNSYLVANIA TO BE USED IN THE OPERATION OF THE BUSINESS: (THIS INFORMATION NOT REQUIRED ON TRANSPORTER-FOR-HIRE APPLICATIONS) LOCATION PURPOSE FOR WHICH PREMISES WILL BE USED NAME OF OWNER OF PREMISES DEED BOOK ADDRESS OF OWNER OF PREMISES VOL. PAGE NO. NO. NAME AND TITLE OF OFFICERS, DIRECTORS, SHAREHOLDERS, PARTNERS, OR MEMBERS OF PROPERTY OWNER (ATTACH SEPARATE SHEET IF NECESSARY) A. B. C. DO NOT WRITE BELOW THIS LINE American LegalNet, Inc. www.FormsWorkflow.com 7. CORPORATIONS AND LIMITED LIABILITY COMPANIES ONLY RESOLUTION (A) 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. (B) DESCRIPTION: INCORPORATED/ORGANIZED REGISTERED NAME (C) DATE PLACE If an out-of-state corporation or limited liability company (except Transporter-for-Hire) list the date of registration with the Pennsylvania Department of State 8. FOR CORPORATIONS ONLY (A) NUMBER OF SHARES OF STOCK ISSUED: PREFERRED COMMON TOTAL (B) 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 9. NAME OF MANAGER – NOT REQUIRED FOR TRANSPORTER-FOR-HIRE OR BAILEE FOR HIRE. NAME OF MANAGER HOME ADDRESS DATE & PLACE OF BIRTH U.S. CITIZEN? YES NO 10. 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) American LegalNet, Inc. www.FormsWorkflow.com APPLICATION FOR LICENSE MANUFACTURE, STORAGE OR TRANSPORTATION PLCB-1350 02/08 COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD BUREAU OF LICENSING (SEE INSTRUCTIONS ON REVERSE) PAGE 2 OF 2 11. If for a distillery of historical significance, was premises established prior to January 1, 1875? YES NO 12. None of the applicants has ever been refused a Federal or State Permit or held a Permit which was cited, suspended or revoked for violations of law, except as follows: (Give details) No Exceptions 13. None of the applicants holds any other license in Pennsylvania authorizing the manufacture or sale of liquor or malt or brewed beverages, except as follows: (If any exceptions, state type of license and address for which issued) No Exceptions 14. None of the applicants is: (A) A member, partner, officer, director, stockholder or creditor of any Pennsylvania Liquor or Malt Beverage Licensee; (B) The owner, proprietor or lessor of any place covered by any type of Pennsylvania Liquor or Malt Beverage License; (C) Financially interested, either directly or indirectly, in the profits of any other business licensed by the Pennsylvania Liquor Control Board, except as follows: (If any exceptions, give details) No Exceptions 15. None of the applicants is interested or engaged elsewhere in any other type of business, except as follows: (Give details) No Exceptions 16. None of the applicants holds any public office which involves the duty to enforce any penal laws of the United States or Pennsylvania, or any penal ordinance or resolution of any Municipal Sub-division of Pennsylvania, nor does any such officer have any interest directly or indirectly in the business, except as follows: No Exceptions 17. No other person is pecuniarily interested directly or indirectly in the business for which license is applied nor will any other person become so interested during the continuance of the license, if granted, except as follows: No Exceptions 18. ALTERNATING BREWER AND BREWERY APPLICANTS ONLY In conjunction with the operation of the Brewery, is Application to be made for a Brewery Pub? YES NO 19. ALTERNATING BREWER AND BREWERY APPLICANTS ONLY – List Federal brewer’s notice registration number: 20. ALTERNATING BREWER’S APPLICANTS ONLY: List name of PA Licensed Brewery at whose premises you will operate, including LID: I swear or affirm, subject to the penalties provided by 18 Pa. C.S. §4904 and 47 P.S. §4-436(j) and §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 The Application for License Manufacture, Storage or Transportation, is to be filed to apply for a new Alternating Brewer, Brewery, Distillery, Distillery of Historical Significance, Winery, Limited Winery, Bonded Warehouse, Bailee for Hire or Transporter-for-Hire, AND to apply for the transfer of Transporter-for-Hire, Class B (in Pennsylvania ONLY), Alternating Brewery or Brewery. All questions must be answered. All attached separate sheets must include the applicant’s name and the address of the establishment. Fees and documents to be submitted with this application include: 1. FEES – For a new license application, a filing fee of $700.00, AND a license fee of: a. $1,425.00 (pro-rated quarterly) for a Alternating Brewer or Brewery, OR b. $265.00 (pro-rated quarterly) for a Bailee for Hire, Bonded Warehouse, Transporter-for-Hire, Class A, OR c. $385.00 (pro-rated quarterly) for a Limited Winery, or for a Winery, OR d. $5,400.00 (pro-rated quarterly) for a Distillery, or for a Distillery of Historical Significance, OR e. $160.00 for a Transporter-for-Hire, Class B, OR f. $265.00 for a Transporter-for-Hire, Class C. The fee to transfer an existing Transporter-for-Hire, Class B, in Pennsylvania ONLY, Alternating Brewery or Brewery, is $650.00 for person to person, $550.00 for place to place, OR $700.00 for both person to person and place to place. Make all remittances payable to “PLCB” or “Commonwealth of Pennsylvania.” Fees submitted by applicants from outside of Pennsylvania MUST be certified checks or money orders. 2. 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, member, OR for a corporation, of each officer, directory, stockholder, and manager. 3. Tax Certification Statement (PLCB-1898) by applicants for Transporter-for-Hire, Class B, located in Pennsylvania AND by applicants for Alternate Brewer and Brewery. 4. A request for Criminal Record Check (PLCB-2018) by applicants for Bailee for Hire, Brewery, Distillery, Limited Winery and Winery for EACH individual applying as an individual licensee, or as a partner, or as a member, or as an officer of a corporation, or manager, with a $10.00 remittance per form. 5. Blue prints of the plant, property and apparatus by applicants for Brewery, Distillery, Winery and Limited Winery. 6. Alternating Brewer and Brewery applicants may apply for a “Brewery Pub” license to operate a restaurant or brew pub on the licensed premise permitting sale of malt or brewed beverages produced and owned by the Alternating Brewer or Brewery respectively. A separate application packet is required. 7. If for transfer of an existing Transporter-for-Hire, Class B (in Pennsylvania ONLY), Alternating Brewer or Brewery, PLCB-21, Application for Transfer of License and Permit. 8. Owner of premises name, address, principals and their titles must be listed. INFORMATION DO NOT SUBMIT ANY OTHER DOCUMENT (E.G.; LEASE, AGREEMENT) WITH THIS APPLICATION PACKET. SHOULD YOU BE REQUIRED TO SUBMIT SUCH DOCUMENTATION, OTHER THAN FOR THE INVESTIGATION OFFICER’S REVIEW, YOU WILL BE NOTIFIED IN WRITING. IF VEHICLES ARE USED TO TRANSPORT LIQUOR, MALT OR BREWED BEVERAGES OR ALCOHOL IN THE REGULAR OPERATION OF THE BUSINESS, YOU ARE REQUIRED TO: 1. Display on each side of each vehicle used to transport alcoholic beverages, the license number (preceded by PLCB), the licensee name and address including the street name and number as shown on the license in letters no smaller than 4 inches in height. Transporters-for-Hire are exempt from the requirement. 2. Own or lease the vehicle used. The vehicle owner may not have any proprietary interest in any business licensed by the board. 3. A Transporter-for-Hire may transport alcoholic beverages as dictated by the permit type, in vehicles owned or leased by the licensee and operated by drivers employed by the Transporter-for-Hire, or operated by unlicensed transporters who are under contract with the Transporter-for-Hire. 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. 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