PLCB-56 5/08 APPLICATION FOR REPLACEMENT LICENSE, PERMIT OR PURCHASE CARDS COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD BUREAU OF LICENSING 10A (SUBMIT ORIGINAL ONLY - SEE INSTRUCTIONS BELOW) The undersigned holder hereby applies for replacement of: LICENSE ONLY PERMIT LICENSE AND PURCHASE CARDS PURCHASE CARDS (STORE DISCOUNT CARD AND LICENSEE DISCOUNT CARD) 1. TYPE OF LICENSE OR PERMIT LICENSE OR PERMIT NO. 2. NAME OF LICENSEE OR PERMITTEE LID NO. 3. ADDRESS OF PREMISES (STREET, RURAL ROUTE, P.O. BOX NO.) 4. NAME OF MUNICIPALITY (POST OFFICE) TYPE OF MUNICIPALITY CITY BORO TWP. INC. TOWN (STATE) (ZIP) COUNTY 5. REASON FOR REQUIRING REPLACEMENT SIGNATURE TITLE SIGNATURE TITLE HOME ADDRESS PHONE HOME ADDRESS PHONE ( ) ( DATE SIGNED STORE STAMP (SEE INSTRUCTION 2) ) DATE SIGNED STATE STORE NO. INSTRUCTIONS 1. A fee of ten dollars ($10.00) MUST ACCOMPANY THIS APPLICATION, made payable to "PLCB" or "Commonwealth of Pennsylvania". 2. State Store stamp is not required unless application is filed with State Store; however, store number must be listed. 3. If licensee is a partnership, corporation or club, the signature of only one partner or secretary of the corporation or club is required. 4. In answering Question 5 give complete details. If application is for Wholesale Purchase Permit Cards (store discount card and licensee discount card), file application with the State Store where present store discount card is deposited. New cards will be mailed directly to State Store. 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