Page 1 of 3 Form L-N (12/2017) P RIVATE CLUB P REQUALIFICATION PACKET L-N ( 1 2 /201 7 ) Contact your local TABC office to verify requirements of Section 11.391 and 61.381 Submit the completed packet to your local TABC office for processing. All statutory references mentioned in this application refer to and can be found in the Texas Alcoholic Beverage Code located on our website. www.tabc.texas.gov/laws/codeandrules.asp LOCATION INFORMATION 1. Type of Private Club Permit N Private Club Registration Permit N L Private Club Late Hours Permit NB Private Club Beer and Wine Permit PE Beverage Cartage Permit NE Private Club Exemption Certificate Permit FB Food and Beverage Ce rtificate 2. Indicate Primary Business at this Location Restaurant Sporting Arena, Civic Center, Hotel Bar Miscellaneo u s Sexually Oriented 3. Trade Name of Location 4. Location Address City County State Zip Code 5. Mailing Address City State Zip Code 6. Business Phone No. Alternate Phone No. E - mail Address OWNER INFORMATION 7. Type of Owner Incorporated Association of Persons Unincorporated Associatio n of Persons Corporation 8. Name of Owner/ Applicant 9. Are you, the applicant a veteran-owned business? Yes No 1 0. Are you, the applicant a Historically Underutilized Business (HUB)? Yes No 1 1 . All Officers Must Be Listed Below (attach L - OIC if additional space is needed). Last Name First Name MI Title Last Name First Name MI Title Last Name First Name MI Title American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 Form L-N (12/2017) M EASUREMENT INFORMATION 1 2 . If you are not applying for a Food and Beverage Certificate, w ill your business be located within 300 feet of any day care center or child care facility? Yes No If 223YES,224 are the facilities located on different floors or stories of the building? Yes No NOTE: For day care centers and child care facilities measure in a direct line from the nearest property line of the school, day care center or child care facility to the nearest property line of the place of business, and in a direct line across intersections. For multistory building: businesses may be within 300 feet of a day care center or child care facility as long as the facilities are located on different floors of the building. 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. PRIVATE CLUB LATE HOURS PERMIT To determine whether the club is authorized to receive a Private Club Late Hours Permit, answer one of the following questions, whichever is applicable. 1 3 . Is the proposed licensed location in a city or county that was 500,000 or more in population according to the 22nd Decennial Census of the United States as released by the Bureau of the Census on March 12, 2001; or is the proposed licensed location in a city or county that was 800,000 or more according to the last Federal Census (2010)? Yes No 1 4 . If the proposed licensed location is in an unincorporated area of a county has the county commissioner222s court adopted by order the late hours of consumption of alcoholic beverages? Yes No 1 5 . If the proposed licensed location is in an incorporated city/town, has the governing body of the city/town adopted by ordinance the late hours consumption of alcoholic beverages? Yes No 60-DAY SIGN INFORMATION 1 6 . If you were required to post a 60 - day sign as required by Section 11.391 or 61.381 of the Texas Alcohol ic Beverage Code at this location; what exact date was the required sign posted at the location? Exact Date ( M M / D D / Y Y Y Y ) ALL APPLICANTS 15 . 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 3 Form L-N (12/2017) WARNING AND SIGNATURE An Officer Must Sign 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 S WEARING TO A LL INFORMATION AND A TTACHMENTS TO THIS P ACKET. 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 COMP TROLLER OF PUBLIC ACCOUNTS CERTIFICATE 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 N, NL, NE & NB) Name of newspaper ATTACH PRINTED COPY OF THE NOTICE HERE City, County Dates notice published in daily/weekly newspaper ( M M / D D / Y Y Y Y ) 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