STATE OF SOUTH CAROLINA DEPARTMENT OF REVENUE ABL-230 APPLICATION FOR CHANGE OF PERSON DESIGNATED TO HOLD A LICENSE OR PERMIT (Rev. 9/13/99) 4268 MAIL TO: South Carolina Department of Revenue, ABL Section, Columbia, SC 29214-0904. Current license numbers: B/W S/C Retail Liquor IMPORTANT: Under S.C. Code Ann. Section 61-3-425 (Supp. 1993), we may not issue a license and/or permit if you have an outstanding tax liability with the SC Department of Revenue or the Internal Revenue Service. ONLY NECESSARY FOR PUBLICALLY HELD CORPORATIONS. 1. Corporation name Trade name 2. Licensed location address (street name/number/route/box) (city) (county) 3. Name of new officer (first) (MI) (last) (title of officer) 4. New officer's home address (do not list a PO Box) (street name/number/route/box) Daytime telephone number (city) (county) (zip code) Business mailing address (include zip code) 5. Social security number Date of birth Race Sex 6. Within the past ten years, have you been convicted of a crime that carried a maximum sentence of two years or more? Yes No. Answer "yes" if you were charged and convicted of a crime for which you could have been sentenced to two years or more, even though your actual sentence was less than two years or you received probation. If "yes" give details on the reverse side of this form. Yes No 7. Have you ever had suspended or revoked any type of alcohol license issued by this department? If "yes", give details on the reverse side of this form. (Must be at least 30 days prior 8. On what date did you establish your residency in South Carolina? to application). 9. Has there been a change of ownership, possession or control of this business or of the corporation since the Yes No If "yes", give details on the reverse side of this form. original license or permit was issued? . 10. How many retail liquor licenses are currently in your name and/or the corporate name 11. Enclose the corporate minutes electing you an officer of the corporation, or a statement from the chief executive officer designating you as the person to hold the license/permit. This application cannot be processed without this information. 12. A records check obtained from the SLED Criminal Justice Information Center must accompany this application. You may obtain a records check in person at SLED, 4400 Broad River Rd, Columbia, SC between the hours of 8:30 a.m. and 5:00 p.m., or you may obtain a records check by mail. Forward your request to SLED, PO Box 21398, Columbia, SC 29221-1398, ATTN: Criminal Records Dept. You must enclose a self-addressed stamped envelope and furnish your full name, social security number and date of birth. Record checks require a $25.00 fee payable by money order or business check made out to SLED - NO PERSONAL CHECKS ARE ACCEPTED. We will not accept this form without a SLED records check attached. IT WILL BE RETURNED TO YOU. Under penalty of perjury, I do hereby attest, that by my signature below, the answers given on this application are true and that I have not falsified any information. I consent to the search of the premises, covered by the license and/or permit, to any SLED agent, law enforcement agent or agent of the SC Department of Revenue. If you fail to answer any question on this application, it will be returned to you. Signature of responsible person American LegalNet, Inc. www.FormsWorkflow.com Supplemental information page for questions #6,7 and 9. List the question number next to your response. ABL 230 (Rev. 9/13/99) American LegalNet, Inc. www.FormsWorkflow.com