Page 1 of 4 Form L-OFF (12/2017) OFF-PREMISE PREQUALIFICATION PACKET L-OFF ( 12/2017 ) Submit this packet to t he proper governmental entities to obtain certification for the type of license/pe rmit for which you are applying as required by Sections 11.37, 11.39, 11.46(b), 61.37, 61.38, 61.42 and Rule 24733.13 All statutory and rule references mentioned in this application refer to and can be found in the Texas Alcoholic Beverage Code or Rules located on our website. www.tabc.texas.gov/laws/codeandrules.asp LOCATION INFORMATION 1. A pplication for: Original Reinstatement License/Permit Nu mber Change of Licensed Location Licen se/Permit Number 2 . Type of Off - Premise License/Permit BQ Wine and Beer Retailer222s Off - Premise Permit LP Local Distributor222s Permit BF Beer Retail Dealer222s Off-Premise License E Local Cartage Permit P Package Store Permit ET Local Cartage Transfer Permit Q Wine Only Package Store Permit PS Package Store Tasting Permit 3 . Indicate Primary Business at this Location Grocery/Market Convenience Store without Gas Liquor Store Miscellaneous Convenience Store with Gas 4 . Trade Name of Location 5 . Location Address County State Zip Code 6 . Mailing Address City State Zip Code 7 . Business Phone No. Alternate Phone No. E - mail Address OWNER INFORMATION 8 . Type of Owner Individual Corporation City/County/University Partnership Limited Liability Company Othe r Limited Partnership Joint Venture Limited Liability Partnership Trust 9 . Business Owner/Applicant 10. Are you, the applicant a veteran-owned business? Yes No 11. Are you, the applicant a Historically Underutilized Business (HUB)? Yes No American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 4 Form L-OFF (12/2017) 12 . As indicated on the chart, enter the individuals that pertain to your business type: (For additional space, use Form L-OIC) Individual/Individual Owner Limited Liability Company/All Officers or Managers Partnership/All Partners Joint Venture/Venturers Limited Partnership/All General Partners Trust/Trustee(s) Corporation/All Officers City, County, University/Official Last Name First Name MI Title Last Name First Name MI Title Last Name First Name MI Title Last Name First Name MI Title MEASUREMENT INFORMATION Section 109.31 et. seq. 13. Will your business be located within 300 feet of a church or public hospital? Yes No NOTE: For churches or public hospitals measure from front door to front door, along the property lines of the street fronts and in a direct line across intersections. 14. Will your business be located within 300 feet of any private/public school? Yes No NOTE: NOTE: For private/public schools measure in a direct line from the nearest property line of the school to the nearest property line of the place of business, and in a direct line across intersections. If located on or above the fifth story of a multistory building: measure in a direct line from the property line of the private/public school to property line of your place of business in a direct line across intersections vertically up the building at the property line to the base of the floor on which your business is located. 15. Will your business be located within 1,000 feet of a private school? Yes No 16. Will your business be located within 1,000 feet of a public school? Yes No ALL APPLICANTS 17. CHECK HERE IF NOT IN CITY LIMITS I, the applicant, have confirmed I am not located in the city limits of any city and therefore all city certificates are not required. American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 4 Form L-OFF (12/2017) WARNING AND SIGNATURE If Applicant Is/ Must Sign Individual/Individual Owner Corporation/Officer Partnership/Partner Limited Liability Company/ Officer or Manager Limited Partnership/General Partner WARNING: Section 101.69 of the Texas Alcoholic Beverage Code states: 223205a 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 Texas Department of Criminal Justice for not less than 2 nor more than 10 years.224 BY SIGNING YOU ARE SWEARING TO ALL INFORMATION AND ATTACHMENTS TO THIS PACKET. PRINT NAME SIGN HERE TITLE Before me, the undersigned authority, on this day of , 20 , the person whose name is signed to the foregoing application personally appeared 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 S E A L CERTIFICATE OF CITY SECRETARY ( FOR P, Q, BF & BQ) Sections 11.37 & 61.37 I hereby certify on this day of , 20 , that the location for which the license/permit is sought is inside the boundaries of this city or town, in a 223wet224 area for such license/permit, and not prohibited by charter or ordinance in reference to the sale of such alcoholic beverages. SIGN HERE , TEXAS City Secretary/Clerk City S E A L CERTIFICATE OF COUNTY CLERK ( FOR P, Q & B F ) Sections 11.37 & 61.37 I hereby certify on this day of , 20 , that the location for which the license/permit is sought is in a 223wet224 area for such license/permit, and is not prohibited by any valid order of the Commissioner222s Court. SIGN HERE COUNTY County Clerk S E A L American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 4 Form L-OFF (12/2017) CERTIFICATE OF COUNTY CLERK ( FOR BQ ) Section 11.37 I hereby certify on this day of , 20 , that the location for which the license/permit is sought as the place of business is in a 223wet224 area and is not prohibited by any valid order of the Commissioner222s Court for a Wine and Beer Retailer222s Off-Premise Permit. Most current election for given location was held for: legal sale of all alcoholic beverages for off-premise consumption legal sale of all alcoholic beverages legal sale of all alcoholic beverages except mixed beverages legal sale of all alcoholic beverages including mixed beverages legal sale of mixed beverages legal sale of mixed beverages in restaurants by food and beverage certificate holders legal sale of wine on the premises of a holder of a winery permit legal sale of beer/wine (17%) on-premise or beer/wine off-premise AFTER Sept. 1,1999 legal sale of beer/wine (14%) on-premise or beer/wine off-premise BEFORE Sept. 1,1999 SIGN HERE COUNTY County Clerk S E A L COMPTROLLER OF PUBLIC ACCOUNTS CERTIFICATE Sections 11.46(b) & 61.42(b) This is to certify on this day of , 20 , the applicant holds or has applied for and satisfies all legal requirements for the issuance of a Sales Tax Permit under the Limited Sales, Excise and Use Tax Act or the applicant as of this date is not required to hold a Sales Tax Permit. Sales Tax Permit Number Outlet Number Print Name of Comptroller Employee Print Title of Comptroller Employee SIGN HERE FIELD OFFICE S E A L PUBLISHER222S AFFIDAVIT (FOR BQ, BF, P & Q ) Sections 11.39 & 61.38 Name of newspaper ATTACH PRINTED COPY OF THE NOTICE HERE City, County Dates notice published in da ily/weekly newspaper (MM/DD/YYYY ) Publisher or designee certifies attached notice was published in newspaper stated on dates shown. Signature of publisher or designee Sworn to and subscribed before me on this date Signature of Notary Public S E A L American LegalNet, Inc. www.FormsWorkFlow.com