PLCB-866 2/12 I COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD NOTICE OF CHANGE IN THE BUSINESS STRUCTURE OF LICENSED CORPORATIONS, LIMITED LIABILITY COMPANIES OR LIMITED PARTNERSHIPS, EXCEPT CLUBS (SEE INSTRUCTIONS PAGE 2 OF 2) BUREAU OF LICENSING PAGE 1 OF 2 Date The following change is reported in accordance with existing regulations of the Pennsylvania Liquor Control Board. This notice is to be attached to and become a part of the original application: 1. NAME OF APPLICANT 2. TRADE NAME (IF ANY) 3. ADDRESS OF PREMISES (STREET, RURAL ROUTE, P.O. BOX NO.) (POST OFFICE) (STATE) (ZIP) LID NO. LICENSE NO. 4. NAME AND ADDRESS OF OWNER OF PREMISES 5. COMPLETE IN DETAIL - (ATTACH SEPARATE SHEET, IF NECESSARY) NAMES OF ALL OFFICERS, DIRECTORS, MEMBERS, PARTNERS, TRUSTEES, STOCKHOLDERS, AND MANAGER A B C D E F TITLE FORMER TITLE IF ANY DATE OF ELECTION NO. OF SHARES DATE STOCK PURCHASED U.S. CITIZEN? YES A B C D E F NO DATE AND PLACE OF BIRTH LENGTH OF RESIDENCE IN PA. HOME ADDRESS STATE OTHER EMPLOYMENT OR BUSINESS 6. LIST ALL FORMER OFFICERS, DIRECTORS, MEMBERS, PARTNERS, TRUSTEES, STOCKHOLDERS OR MANAGER WHOSE RELATION WITH THE APPLICANT IN SUCH CAPACITY HAS BEEN DISCONTINUED SINCE THE LAST INFORMATION WAS FILED. (ATTACH SEPARATE SHEET, IF NECESSARY.) NAME IF FORMER OFFICER OR STOCKHOLDER LIST TITLE(S) NO. SHARES SOLD, IF ANY HOME ADDRESS DO NOT WRITE BELOW THIS LINE American LegalNet, Inc. www.FormsWorkFlow.com 17. CONVICTION RECORD: The following is a record of ALL felony and misdemeanor convictions of new and continuing officers, directors, members, partners, trustees, stockholders, and manager. (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) 18. Are any of the officers, directors, members, partners, trustees, stockholders, or manager: YES NO YES NO A. Officers, directors, members, partners, trustees, stockholders or creditors of any other licensee? B. Owners, proprietors or lessors of any place licensed by this Board? C. Financially interested, either directly or indirectly, in the profits of any manufacturer or any business licensed by the Board? D. Public officials enforcing penal laws, either by appointment or election? E. Employees of any licensee? F. Holders of any license issued by this Board? G. Employees of the Pennsylvania Liquor Control Board? 19. Name the persons involved and explain any affirmative answer to question 8. 10. Does the applicant hold any other license issued by this board? YES NO If "Yes," give LID No.(s) If five licenses or more, attach separate sheet, giving LID, license number and address of premises. 11. Is a management company employed? YES YES NO NO List name of management company RESOLUTION If "Yes," was it reported to the PLCB? 12. At a regular or special meeting held on and/or (NAME/TITLE) (NAME/TITLE) , 20 by the applicant, is/are hereby it was resolved that said notice be filed with the Pennsylvania Liquor Control Board, and that authorized to execute said notice, and any other papers required by the Board. 13. DATE "PUBLIC NOTICE OF APPLICATION ALCOHOLIC BEVERAGES" (PLACARD PLCB-1296) WAS POSTED. 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 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 PHONE HOME ADDRESS PHONE DATE SIGNED PREMISES PHONE NO. E-MAIL ADDRESS American LegalNet, Inc. www.FormsWorkFlow.com PLCB-866 2/12 COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD NOTICE OF CHANGE IN THE BUSINESS STRUCTURE OF LICENSED CORPORATIONS, LIMITED LIABILITY COMPANIES OR LIMITED PARTNERSHIPS, EXCEPT CLUBS BUREAU OF LICENSING PAGE 2 OF 2 INSTRUCTIONS This form is to be used, except by clubs, to report any change in the licensed business's members, partners, officers, directors, or stockholders. It is also to reflect a change to the manager IF the manager is also changing other positions (e.g., president and manager). If the applicant is reporting a change to manager ONLY, PLCB-706, Application for Approval of Appointment of Manager, MUST be used. This form may also be used to report changes in a "limited liability company" (L.L.C.) or a business trust. Fees and documents to be submitted include: 1. APPLICATION PLCB-866 ­ All questions must be answered and the form must be signed in accordance with the resolution. List all officers, directors, stockholders, and manager of the corporation; all members and manager of a limited liability company; all partners and manager of a limited partnership; or all trustees and manager of a business trust, as directed. If applicant holds or is applying for a retail license, list only stockholders holding 10% or more of stock. List all stockholders for manufacturers, distributor and importing distributor license. 2. PLCB-1773, Appendix Social Security Information MUST be submitted showing the social security number(s), name(s), and title(s) of each officer, director, member, partner, trustee, stockholder, and manager. 3. FEES ­ The fee is $200.00 if this change is not to the majority and/or controlling interest of the business structure, otherwise to report a change to the majority and/or controlling interest of the business structure the fee is $650.00. Make remittances payable to "PLCB" or "Commonwealth of Pennsylvania." A fee submitted from out-of-state must be in the form of a certified check or money order. 4. PHOTOGRAPHS ­ Applicants holding Restaurant, Hotel, Eating Place and other retail licenses, or distributor or importing distributor licenses MUST submit recent, individual photograph(s), 1½" x 1½" in size, of each of the new member, partner, president, secretary, treasurer, and manager. The name of the person and the name and address of the applicant must appear on the reverse of each photograph. The photograph(s) must have a matte finish. 5. PLCB-2018, Request for Criminal Record Check MUST be submitted for each newly elected individual with a $10.00 fee per form. INFORMATION If the change is to the majority stockholder(s), PLCB-1296, Placard ­ Public Notice of Application Alcoholic Beverages, MUST BE POSTED on the licensed premises, and the PLCB-193, Affidavit of Comp