APPLICATION FOR RETAILER’S PERMIT OR LICENSE FORM L-101-A (12/2007) TABC USE ONLY ISSUE DATE FEE LATE FEE (RENEWAL ONLY) SURCHARGE 1A. APPLICATION FILED FOR: Registry No. BG WINE AND BEER RETAILER’S PERMIT BE BEER RETAIL DEALER’S ON-PREMISE LICENSE PS PACKAGE STORE TASTING PERMIT BQ WINE AND BEER RETAILER’S OFF-PREMISE PERMIT N PRIVATE CLUB REGISTRATION PERMIT BF BEER RETAIL DEALER’S OFF-PREMISE LICENSE NB PRIVATE CLUB BEER AND WINE PERMIT BL RETAIL DEALER’S ON-PREMISE LATE HOURS LICENSE NE PRIVATE CLUB EXEMPTION CERTIFICATE PERMIT BP BREWPUB LICENSE NL PRIVATE CLUB LATE HOURS PERMIT V WINE & BEER RETAILER’S PERMIT FOR EXCURSION BOATS PE BEVERAGE CARTAGE PERMIT Y WINE & BEER RETAILER’S PERMIT FOR RAILWAY DINING CAR MB MIXED BEVERAGE PERMIT P PACKAGE STORE PERMIT LB MIXED BEVERAGE LATE HOURS PERMIT Q WINE-ONLY PACKAGE STORE PERMIT MI MINIBAR PERMIT LP LOCAL DISTRIBUTOR’S PERMIT CB CATERER’S PERMIT LOCAL CARTAGE PERMIT FB FOOD AND BEVERAGE CERTIFICATE LOCAL CARTAGE TRANSFER PERMIT RM MIXED BEVERAGE RESTAURANT PERMIT WITH FB E ET B. APPLICATION IS FOR: Original Renewal Renewal Change Change of C. If renewal or change, enter license/permit no(s). FOR ALL RETAILERS D. If applying for subordinate only, enter primary license/permit no. 2A. Applicant is: Individual Corporation Joint Venture Partnership Limited Liability Company Limited Partnership Other: Trust City/University Limited Liability Partnership Unincorporated Association of Persons (Private Clubs Only) B. Indicate primary business at this location: 01 - Restaurant 05 - Miscellaneous: 10 - Pari-mutuel Wagering 02 - Bar 06 - Grocery/Market 03 - Sexually Oriented 07 - Liquor Store 11 - Convenience Store with Gas 12 - Convenience Store without Gas 04 - Sporting Arena, Civic Center, Hotel 08 - Gas Station C. Does the applicant require employees to attend an agency-approved seller training course? 2C. E. Has the proposed licensed location been reviewed for compliance with Title III of the Americans with Disabilities Act of 1990? F. Does the applicant own the land and building at the proposed licensed location? Yes No D. E. Yes No Yes No F. D. Is live music featured two or more times per week? Yes No G. If location has not been licensed within the last 24 months for on-premise consumption of alcoholic beverages, indicate the date sign was posted: / / INSTRUCTIONS: All applicants complete questions 3-6. Individual Business Owners ALSO complete question 7. 3. Trade Name of Business 4. Location Address WINE % FOR BG/BQ City County State TX ZIP Code (9 digits) - 5. Mailing Address City State ZIP Code (9 digits) - 6. FOR INDIVIDUAL TABC USE ONLY Area Code + Business Phone No. ( ) - 7. Social Security Number of Individual - Area Code + Alternate Phone No. ( ) - CITY CODE Applicant’s E-Mail Address (optional) Issuing State/Driver’s License Number Date of Birth (mm/dd/yyyy) / / COUNTY CODE Full Legal Name of Individual (Last, First, Middle) American LegalNet, Inc. www.FormsWorkflow.com