APPLICATION FOR PROMOTIONAL PERMIT TABC USE ONLY TRADE NAME: FORM L-107 (9/2011) ISSUE DATE FEE $600 PR- SURCHARGE LATE FEE (RENEWAL ONLY) $376 FIRST READ ALL INSTRUCTIONS - TYPE OR PRINT IN INK 1. APPLICATION IS FOR: Original Registry No. Renewal/Change Change of: ALL APPLICANTS If renewal or change, enter the permit no.: PR2. APPLICANT IS: Individual Limited Partnership Corporation Limited Liability Partnership Limited Liability Company Other Partnership 3. Trade Name of Business 4. Mailing Address City 5. Business Telephone Number ( ) - Alternate Telephone Number ( ) - Zip Code (9 digits) - City Address of Location State State Zip Code (9 digits) - E-Mail Address (optional) INDIVIDUALS INSTRUCTIONS: If Individual Owner, complete question 7 & 8. For all others, refer to Instructions on this page. 7. Social Security Number - Issuing State /Driver’s License Number Date of Birth (mm/dd/yyyy) / / Full Legal Name (Last, First, Middle) Residential Address City State Zip Code (9 digits) - 8. Has the person named in 7 above been a legal resident of Texas for one year immediately preceding CORPORATION(S), LLC(S) & PARTNERSHIP(S) the filing of this application? 8. YES NO INSTRUCTIONS FOR: CORPORATION, LIMITED LIABILITY COMPANY, PARTNERSHIP, LIMITED PARTNERSHIP, LIMITED LIABILITY PARTNERSHIP, OTHER. For Corporations or Limited Liability Companies: Complete L-107-C for all officer(s), director(s), manager(s), stockholder(s), and member(s). If applicant is a publicly held corporation: Provide pertinent information as indicated in 4 on L-107-C on all stockholders holding 5% or more of the shares. For Partnership, Limited Partnership, or Limited Liability Partnership: Complete L-107-P ensuring you include all partners involved in business. If one or more of your general or limited partners is a limited partnership or limited liability partnership complete L-107-P for each partnership. If one or more of your General or Limited Partners is a Corporation: Complete L-107-C TABC USE ONLY for each corporation or limited liability company. INITIAL APPLICATION INCOMPLETE ADDITIONAL CORRESPONDENCE YES - NO YES - NO PROCESS DATE: PROCESSOR I.D.: / PROCESSOR REVIEW DATE: / / / PROCESSOR ERROR YES - NO Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com CORPORATION TRADE NAME: FOR CORPORATION OR LIMITED LIABILITY COMPANY-OFFICER(S) AND DIRECTOR(S) OR CORPORATION, OFFICER(S) AND MANAGER(S) OF LIMITED LIABILITY COMPANY, STOCKHOLDERS/MEMBERS 1. FORM L-107-C (11/2005) If applicant is a corporation or limited liability company, enter the following information: A. Federal Employer’s I.D. No. B. Entity Name C. Charter No. Date Approved / / State D. Number and class of shares, memberships or units issued: 2. Are at least 51% of each class of shares, memberships, or units issued owned by persons who are at least 21 years of age or older? 3. Have the persons in 3 A, B and C, legally resided in Texas for at least one year immediately preceding the filing of this application? A. All officers? B. 51% of owners of each class of shares, memberships, or units issued? C. Majority of directors? 4.↓ COMPLETE THE FOLLOWING PER INSTRUCTIONS: Social Security Number Issuing State/ Driver’s License Number Full Legal Name (Last, First, Middle) Officer Director/ Manager Residential Address Social Security Number - Issuing State/ Driver’s License Number Officer Director/ Manager Residential Address Issuing State/ Driver’s License Number Officer Director/ Manager Issuing State/ Driver’s License Number Full Legal Name (Last, First, Middle) Officer Director/ Manager Residential Address Class & No. of Shares, Memberships or Units Held Stockholder/Member Position/Title State Date of Birth (mm/dd/yyyy) / / Class & No. of Shares, Memberships or Units Held Stockholder/Member ZIP Code (9 digits) - Position/Title State Date of Birth (mm/dd/yyyy) / / Class & No. of Shares, Memberships or Units Held Stockholder/Member ZIP Code (9 digits) - Position/Title State Date of Birth (mm/dd/yyyy) / / Class & No. of Shares, Memberships or Units Held Stockholder/Member ZIP Code (9 digits) - Position/Title City Issuing State/ Driver’s License Number Full Legal Name (Last, First, Middle) Residential Address YES NO YES NO YES NO City Residential Address Social Security Number - 3A. B. C. City Full Legal Name (Last, First, Middle) Social Security Number - YES NO City Full Legal Name (Last, First, Middle) Social Security Number - Date of Birth (mm/dd/yyyy) / / 2. Officer Director/ Manager State Date of Birth (mm/dd/yyyy) / / Class & No. of Shares, Memberships or Units Held Stockholder/Member City State ZIP Code (9 digits) - Position/Title ZIP Code (9 digits) - (IF MORE SPACE IS NEEDED, USE ADDITIONAL COPIES OF THIS PAGE.) Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com PARTNERSHIP TRADE NAME: FORM L-107-P (11/2005) 1. Have all partners of the general partnership or all general partners and 51% of the total ownership of FOR ALL PARTNERS – NAMES OF PARTNER(S), LIMITED PARTNER(S) AND GENERAL PARTNER(S) the limited partnership or limited liability partnership legally resided in Texas for at least one year immediately preceding the filing of this application? 1. YES NO 2. All limited partnerships and limited liability partnerships must enter: A. Federal Employer’s I.D. No.: B. Entity Name: C. Date Approved (mm/dd/yyyy): / / State: 3.↓ COMPLETE THE FOLLOWING PER INSTRUCTIONS: Social Security Number - Issuing State/ Driver’s License Number Full Legal Name of Partner (Last, First, Middle) General Partner Residential Address Social Security Number - City Issuing State/ Driver’s License Number Full Legal Name of Partner (Last, First, Middle) General Partner Residential Address Social Security Number - Issuing State/ Driver’s License Number General Partner Residential Address Issuing State/ Driver’s License Number General Partner Residential Address Limited Partner City Issuing State/ Driver’s License Number Full Legal Name of Partner (Last, First, Middle) Residential Address Limited Partner City Full Legal Name of Partner (Last, First, Middle) Social Security Number - Limited Partner City Full Legal Name of Partner (Last, First, Middle) Social Security Number - Limited Partner General Partner Limited Partner City Date of Birth (mm/dd/yyyy) / / % of Interest State ZIP Code (9 Digits) - Date of Birth (mm/dd/yyyy) / / % of Interest State ZIP Code (9 Digits) - Date of Birth (mm/dd/yyyy) / / % of Interest State ZIP Code (9 Digits) - Date of Birth (mm/dd/yyyy) / / % of Interest State ZIP Code (9 Digits) - Date of Birth (mm/dd/yyyy) / / % of Interest State ZIP Code (9 Digits) - (IF YOU NEED MORE SPACE FOR PARTNERS, MAKE ADDITIONAL COPIES OF THIS PAGE. COMPLETE FORM L-107-C FOR CORPORATIONS AND LIMITED LIABILITY COMPANIES THAT ARE GENERAL OR LIMITED PARTNERS.) Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR PROMOTIONAL PERMIT CONTINUED TRADE NAME: FORM L-107 (9/2011) The applicant or holder of a Promotional Permit MAY NOT hold an interest, directly or indirectly in an entity holding a permit or license issued by the Texas Alcoholic Beverage Commission. You or your agent, servant or employee MAY NOT: • be employed in any capacity by a permit/license holder except for the contract to promote and enhance alcoholic beverages for promotional events • rent or lease property or equipment from or to an entity holding a permit/license in Texas, • secure credit or a loan in any form for an entity holding a permit/license in Texas, • control in any fashion the interests of a permittee or licensee in Texas, • hold a license or permit of any other type issued in Texas. 9. Are you or anyone named in questions 7 on L-107, 4 on L-107-C, or 3 on L-107-P, or your agent, servant or employee in violation of the above requirements? 9. YES NO ACKNOWLEDGMENT ALL APPLICANTS If “YES,” explain below or attach page: 10A. Has any person named in question 7 on L-107, 4 on L-107-C, or 3 on L-107-P or his or her spouse 10A. been finally convicted or received deferred adjudication for a felony offense? B. If answer to 10A is “YES,” has it been five years since the termination of a sentence, parole or probation served for any offenses indicated above? B. If answer to 10B is “NO,” attach an explanation. C. Has any person named in question 7 on L-107, 4 on L-107-C, or 3 on L-107-P been convicted of any offense(s) under federal or state law, or municipal ordinance involving violations of an individual’s civil rights or discrimination against an individual on the basis of race, color, creed or national origin? C. 11. I affirm that I will provide copies of all contracts with licensed/permitted entities to the Texas Alcoholic 11. Beverage Commission Licensing Division in Austin prior to the promotional event. 12. I affirm that all agents, servants, or employees that are participating in promotional events will be provided with employment cards and that these cards must be kept on the person during promotional events and available for inspection by any authorized representative of the Texas Alcoholic Beverage Commission containing: • the name of the promotional permit holder, • the Promotional Permit number, • name of employee, agent or servant, 12. • effective date of employment. YES NO YES NO YES NO YES NO WARNING: Section 101.69 of the Texas Alcoholic Beverage Code states: “…a person who makes a false statement or false representation in an application for a permit or license or in a statement, report, or other instrument to be filed with the Commission and required to be sworn commits an offense punishable by imprisonment in the penitentiary for not less than 2 nor more than 10 years.” If Applicant is: Individual Who Must Sign: Individual Owner PRINT NAME: Partnership Partner SIGN HERE: Corporation Officer SIGNATURE MUST APPEAR AS NAME SHOWN IN QUESTION 7 on L-107, 4 on L-107-C, or 3 on L-107-P. Ltd. Liability Co. Ltd/Ltd Liability Partnership SEAL 1. INSTRUCTIONS YES NO 2. 3. 4. Officer or Manager General Partner Before me, the undersigned authority, on this day of , the person whose name is signed to the foregoing application personally appeared 20 and, duly sworn by me, states under oath that he or she has read the said application and that all the facts therein set forth are true and correct. SIGN HERE: NOTARY PUBLIC Beginning January 1, 2009 the permit covered under this form will be issued for a two-year period. You MUST renew for the entire two-year period. The total amount of fees plus surcharges to cover the two-year period MUST be paid at the time of renewal. Fees may NOT be prorated or refunded. Prepare the application in duplicate. Mail the original application to the Texas Alcoholic Beverage Commission, P.O. Box 13127, Austin, Texas 78711 with the correct permit fees. Keep duplicate for your files. Fee must be paid with Cashier’s Check, Money Order, or Firm Check from a corporate permittee made payable to the Comptroller of Public Accounts. We will NOT accept personal checks. Class of Permit Annual State Fee *Surcharge Effective 9/1/11 Total Due Promotional Permit $600.00 $376.00 $976.00 *Surcharges are subject to annual change. The surcharges assessed each year are determined by the Texas Alcoholic Beverage Commission and not by the Legislature. The Legislature determines the total dollar amount to be raised in agency revenue. The revenue is comprised of fees, which are set by the Legislature, and the surcharges which are determined by the agency. American LegalNet, Inc. www.FormsWorkFlow.com