PLCB-2277 5/05 COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD APPLICATION FOR USE OF MANAGEMENT COMPANY BUREAU OF LICENSING (SEE INSTRUCTIONS ON REVERSE) The following is reported in accordance with existing regulations of the Pennsylvania Liquor Control Board. 1. NAME OF LICENSEE/APPLICANT LID NO. 2. TRADE NAME (IF ANY) LICENSE NO. 3. ADDRESS OF PREMISES (STREET, RURAL ROUTE, P.O. BOX NO.) 4.A DO YOU HOLD ANY OTHER LICENSE ISSUED BY THIS BOARD? 5. (POST OFFICE) (STATE) IF YES, LIST LID NUMBERS YES NO ADDRESS OF MANAGEMENT COMPANY A. NAME OF MANAGEMENT COMPANY B. HAS A WRITTEN AGREEMENT BEEN EXECUTED BETWEEN THE LICENSEE/APPLICANT AND THE MANAGEMENT COMPANY? IF YES, LIST THE DATE OF EXECUTION (ZIP) LIST THE EFFECTIVE DATE YES NO LIST THE EXPIRATION DATE IF NO, EXPLAIN 6. RESPONSIBLE OPERATOR OR CORPORATE SETUP NAME OF INDIVIDUAL APPLICANT, PARTNERS, MEMBERS, OR OFFICERS & DIRECTORS TITLE HOME ADDRESS DATE AND PLACE OF BIRTH U.S. LENGTH OF CITIZEN? RESIDENCE IN PA. YES NO A. NAME B. NAME C. NAME D. NAME DO NOT WRITE BELOW THIS LINE American LegalNet, Inc. www.FormsWorkflow.com RESOLUTION (CORPORATIONS, LIMITED LIABILITY COMPANIES AND CLUBS ONLY) 7. 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 (NAME/TITLE) is/are (NAME/TITLE) hereby 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) and/or §5-504(b) and/or §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 TITLE HOME ADDRESS PHONE ( ) PHONE ( ( ) DATE SIGNED ) INSTRUCTIONS The enclosed forms are to be submitted by a licensee who has contracted with an entity to operate, manage or supervise all or part of the operation of the licensed premises. 1. Application for Use of Management Company (PLCB-2277). 2. Fee, made payable to “PLCB” or “Commonwealth of PA;” in the amount of $350.00 MUST accompany this form. 3. Tax Certification Statement for Management Company (PLCB-1898A), for the management company 4. Appendix Social Security Information (PLCB-1773), MUST be submitted listing the social security number of each individual applicant, all partners, officer, director and stockholder of the management company. INFORMATION A copy of the management agreement MUST be available during the interview process with the Licensing representative. DO NOT submit it with this application, as it will delay the interview process. DO NOT SUBMIT ANY OTHER DOCUMENT (E.G.; LEASE, AGREEMENT) WITH THIS APPLICATION PACKET. SHOULD YOU BE REQUIRED TO SUBMIT ADDITIONAL DOCUMENTATION, OTHER THAN FOR THE INVESTIGATIVE OFFICER’S REVIEW, YOU WILL BE NOTIFIED IN WRITING. 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