PLCB-2297 8/08 APPLICATION FOR OFF-PREMISES SALES PERMIT FOR MALT/BREWED BEVERAGES COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD BUREAU OF LICENSING (FOR LICENSES LOCATED IN 1ST CLASS CITIES) (SEE INSTRUCTIONS ON REVERSE) The undersigned hereby applies for an Off-Premises Sales Permit for the license expiring . 11. NAME OF LICENSEE LICENSE NO. 12. TRADE NAME (IF ANY) LID NO. 13. ADDRESS OF PREMISES 14. (STREET, RURAL ROUTE, P.O. BOX NO.) (POST OFFICE) (STATE) (ZIP) 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 hereby (NAME/TITLE) (NAME/TITLE) 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), that the foregoing answers and statements provided herein are true and complete to the best of my knowledge, information, 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 permit is REQUIRED for Restaurant Liquor (R), Airport Restaurant Liquor (AR), Economic Development Restaurant Liquor (EDR), Municipal Golf Course Liquor (GR), Off Track Wagering Restaurant Liquor (OWR), Privately-Owned Public Golf Course Liquor (PGR), Eating Place Malt Beverage (E), Economic Development Eating Place Malt Beverage (EDE), Municipal Golf Course Malt Beverage (GE) and Privately-Owned Public Golf Course Malt Beverage (PGE) licensees located in 1st class cities to sell malt and/or brewed beverages for off-premises consumption. Off-Premises Sales Permit allows the holder thereof, in conjunction with their retail license, to sell malt and/or brewed beverages to individuals for consumption off of the licensed premises so long as a single sale to one person does not exceed 192 fluid ounces. This permit does not extend the hours for sale of malt and/or brewed beverages. 1. A copy of the Malt and Brewed Beverage Hearing Board’s approval should accompany this application. If you have any questions on how to obtain such approval, please contact the Malt and Brewed Beverage Hearing Board at (215) 685-3784. 2. A filing fee of $300.00 is required. Remittance made payable to the “PLCB” or the “Commonwealth of Pennsylvania.” INFORMATION IF YOU REQUIRE ASSISTANCE IN COMPLETING THE APPLICATION, CALL THE LICENSING INFORMATION CENTER AT (717) 783-8250, OPTION #7. SEND COMPLETED APPLICATION WITH HEARING BOARD APPROVAL AND FILING FEE TO: PENNSYLVANIA LIQUOR CONTROL BOARD, BUREAU OF LICENSING, P.O. BOX 8940, HARRISBURG, PA 17105-8940. American LegalNet, Inc. www.FormsWorkflow.com