SD EForm - 0873 V7 License No.__________________________ Date Recieved_______________________ Date Issued_________________________ Uniform Alcoholic Beverage License Application Mail this copy to: Department of Revenue, Special Tax Division 445 East Capitol Ave Pierre, SD 57501-3100. A. Owner Name and Address B. Business Name and Address Owner's Telephone #: C. Indicate the class of license being applied for (submit separate application for each class of license). Retail (on-sale) Liquor Retail (on-sale) Liquor - Restaurant Retail (on-off sale) Wine Package (off-sale) Liquor Retail (on-off sale) Malt Beverage Retail (on-off sale) Malt Beverage & SD Farm Wine Package (off sale) Malt Beverage Package (off sale) Malt Beverage & SD Farm Wine Other (please classify) Transfer Fee $150.00 Number of other Package Liquor Licenses held: _________ Number of other On-sale Liquor Licenses held: _________ Is this License in active use? [ ] Yes [ ] No H. Business Telephone #: D. Legal description of licensed premise: Have you ever been convicted of a felony? [ ] Yes [ ] No Do you own [ ] or lease [ ] this property? (Check one) E. State Sales Tax Number:________________________________ F. Remember to obtain a Federal Alcohol Stamp, for help call TTB at 1-800-937-8864. G. New license?_____ Transfer? ($150)_____ Re-issuance?_____ CERTIFICATE: The undersigned applicant certifies under the penalties of perjury that all statements provided herein are true and correct; that the said applicant complies with all of the statutory requirements for the class of license being applied for and in addition agrees to permit agents of the Department of Revenue access to the licensed premises and records as provided in SDCL 35-2-2.1, and agrees this application shall constitute a contract between applicant and the State of South Dakota entitling the same or any peace officers to inspect the premises, books and records at any time for the purpose of enforcing the provisions of Title 35 SDCL, as amended. I. Any Application required to be submitted to a local governing board must be signed in the presence of the city or county auditor, the town clerk or notary public. This applies to ALL applications EXCEPT the following: distillers, manufacturers, wholesalers, municipalities, airports, solicitors, dispensers, carriers, transportation companies, and farm wineries. Place of business is located in a municipality? [ ] Yes [ ] No County: __________________________ This application was subscribed and sworn to before me this ________ day of ______________________ Approving Officer's Telephone number ___________________ Signature: _______________________________________________ J. APPROVAL OF LOCAL GOVERNING BODY ­ Notice of hearing was published on ____________________. Public hearing on the application was held ____________________, not less than SEVEN (7) days after official publication. The governing body by majority vote recommends the approval and granting of this license and certifies that requirements as to location and suitability of premises and applicant have been reviewed and conform to the requirements of local and South Dakota law. Application approved for Sunday on-sale operation? [ ] Yes [ ] No Are real property taxes paid to date? [ ] Yes [ ] No Ineligible for video lottery [ ] Number of video lottery terminals on licensed premise: _____________ Amount of fee collected with application $_____________ Amount of fee retained $___________________________ Forwarded with application $ _______________________ For Local Government Use (Seal) _______________________________________ Mayor or Chairman If disapproved, endorse reason thereon and return to applicant Transferred Sales tax approval_________________ (State Use) Date ____________________ From:_______________________________________________________ STATE LIQUOR AUTHORITY: APPROVAL_____ REVIEW_____ Please complete reverse side American LegalNet, Inc. www.FormsWorkFlow.com Company supplement information (For corporate/partnership/LP/LLC applicants) If supplement unchanged from last year check this box and sign below. State of South Dakota :ss County of ) We, the undersigned, being first duly sworn upon oath, supply the following information: Name of corporation/partnership/LP/LLC___________________________________________________________________________ Address of office and principal place of business of corporation/partnership/LP/LLC__________________________________________ Date of incorporation _________________________________________________________________________________________ Date of last report filed with Secretary of State ______________________________________________________________________ Are all managing officers of this corporation/partnership/LP/LLC of good moral character? _____________________________________ Have any of the managing officers of this corporation/partnership/LP/LLC ever been convicted of a felony? ________________________ Name, title of office, occupation and address of each of the officers/owners of the corporation, partnership, LP or LLC: Name Office Address Occupation ) Affidavit Name, address and occupation of each of the directors of the corporation: Name Address Occupation Name and address of each of the stockholders and percentage of shares owned or held by each: Name Address Percentage of Shares Name of any officers, directors, partners or stockholders of applicant having a financial interest or capital stock in any other retail liquor outlet: Name Type of License, Financial Interest Held, and Address of Retail Outlet Where and with whom are all company records kept, such as charter, by-laws, minutes, accounts, notes payable, and notes and accounts receivable, etc? With signature the applicant agrees to the following: That the applicant company will comply with all provisions of ARSD chapter No. 64:75:02 of the Department of Revenue, relating to the transfer of stock and prior approval of the transfer of such stock by the Secretary of Revenue and violation of any of the provisions of said regulation or failure to comply therewith, whether by the undersigned corporation, partnership/LP/LLC or by any stockholder thereof, or by anyone interested in said company, shall constitute cause for revocation or suspension of any license issued pursuant to and in reliance on this application, or for refusal to renew such license upon expiration thereof. We the undersigned officers and directors of the applicant company ackn