UTAH DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL 1625 South 900 West • PO Box 30408 • Salt Lake City, Utah • 84130-0408 (801) 977-6800 • Fax 977-6888 www.abc.utah.gov “LOCAL INDUSTRY REPRESENTITIVE LICENSE” APPLICATION CHECKLIST The items below must be completed and submitted by the 10th of the month before any action can be taken by the Alcoholic Beverage Control Commission. You will be notified of the next monthly commission meeting when your application will be considered for issuance of a license. We request that a representative attend the meeting to make a brief presentation. 1.____Completed application form (enclosed). 2.____Ownership entity organizational papers for business: a) if a corporation, submit a copy of the articles of incorporation; b) if a partnership, submit a copy of the written agreement; c) if a limited liability company, submit a copy of the articles of organization 3.____Criminal history background check information (see application form). 4.____Copy of current local business license. 5.____If applicant holds a federal importer’s permit from the Alcoholic and Tobacco Tax and Trade Bureau, submit a copy. 6.____$50 application fee (non-refundable). 7.____$100 initial license fee (make checks payable to UDABC). Enclosed for your information are summaries of the laws pertaining to local industry representatives in Title 32A of the Utah Code and the rules of the Commission. If you have any questions, please contact our Licensing and Compliance Department at (801)-977-6800. 6.04.08 American LegalNet, Inc. www.FormsWorkflow.com UTAH DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL APPLICATION FOR LOCAL INDUSTRY REPRESENTATIVE LICENSE 1. Business Name: _______________________________________________________________ 2. Applicant/Owner of business: ____________________________________________________ 3. Location: ____________________________________________________________________ Street 4. City State Zip Mailing Address: ______________________________________________________________ Street or PO Box City State Zip 5. Business Phone: ___________________Other Phone: ______________ Fax: ______________ 6. Contact Person: __________________________________________ 7. Ownership: Check appropriate box and provide the requested information in the space below (add additional sheets if necessary). [] Applicant is an individual: List below information for: (a) Individual (b) Managers [] Applicant is a partnership: List below information for: (a) All Partners (b) Managers [] Applicant is a corporation: List below information for: (a) Any Stockholder owning at least 20% of the corporation (b) All Corporate officers (c) Managers [] Applicant is a limited liability company (LLC): List below information for: (a) Any members owning at least 20% of the company (b) Managers TITLE____________NAME_______________________HOME ADDRESS______________________ HOME PHONE#____________DR LIC#_____________SS#___________DOB______%OWNED____ Are you a United States Citizen? ________ If no, must attach a copy of residency status. TITLE____________NAME_______________________HOME ADDRESS______________________ HOME PHONE#____________DR LIC#_____________SS#___________DOB______%OWNED____ Are you a United States Citizen? ________ If no, must attach a copy of residency status. 8. Criminal History. The law prohibits any person who has been convicted of a felony under any federal or state law or any violation of any federal or state law or local ordinance concerning the sale, manufacture, distribution, warehousing, adulteration, or transportation of alcoholic beverage from being in the alcoholic beverage business. The law also prohibits any person who has been convicted of any crime involving moral turpitude or, on two or more occasions within the last five years, has been convicted of driving under the influence of alcohol, or any drug, or the combination of alcohol and any drug from being in the alcohol business. This proscription also applies to any officers, partners, 6.04.08 American LegalNet, Inc. www.FormsWorkflow.com managers, managing agents, directors, stockholders who hold at least 20% of the total issued and outstanding stock of an applicant corporation, members who own at least 20% of an applicant limited liability company and to any person employed to act in a supervisory or managerial capacity. Please list all criminal offenses other than minor traffic offenses of which you or any of the above persons have ever been convicted: NAME CRIMINAL OFFENSE DATE OF CONVICTION In addition, a criminal history background check must be furnished on each person listed above and in subparagraph 7. This may be done as follows: a. Utah residents: If any person listed has been a resident of Utah for at least two years, he/she shall submit a fingerprint card to the DABC and consent to a fingerprint criminal background check by the Utah Bureau of Criminal Identification. b. Non Residents: Out of state residents or persons who have resided in Utah for less than two years shall submit a fingerprint card to the DABC and consent to a fingerprint criminal background check by the Federal Bureau of Investigation (F.B.I). An informed consent and release of liability form is included with this application. Fingerprint cards are available at law enforcement agencies. You may download the fingerprint card at this web address: http://www.fbi.gov/hq/cjisd/pdf/fpcardb.pdf Submit the form(s) to the DABC with a processing fee of: • $15.00 per card for BCI background checks, or • $34.25 per card for FBI background checks. In the case of an undue delay in the processing of an F.B.I. criminal background check, here are the rules and procedures for obtaining a third-party national background check: An application that requires F.B.I. criminal history background report(s) may be included on a commission meeting agenda, and may be considered by the commission for issuance of a license, permit, or package agency if: 1). the applicant has completed all requirements to apply for the license, permit, or package agency other than the department receiving the F.B.I. criminal history background report(s); 2). the applicant attests in writing that he or she is not aware of any criminal conviction of any person identified in the application that would disqualify the applicant from applying for and holding the license, permit, or package agency; 3). the applicant has submitted to the DABC the necessary fingerprint card(s) required for the application and consented to the fingerprint criminal background check(s) by the F.B.I. 4). the applicant at the time of application supplies the department with a current criminal history background report conducted by a third-party background check reporting service on any person for which an F.B.I. background check is required; and 5). the applicant stipulates in writing that if an F.B.I. report shows a criminal conviction that would disqualify the applicant from holding the license, permit, or package agency, the applicant shall immediately surrender the license, permit, or package agency to the department. A suggested attestation/stipulation letter that satisfies the above requirements is enclosed. A third-party national criminal background check can be obtained by; • searching the yellow pages under Background Screening • searching the internet under Background Screening or Background Checks Because the DABC is State Agency, we cannot recommend any one background screening service over another. It is your responsibility however, to obtain the most complete, nationwide, criminal history available for the application process. 6.04.08 American LegalNet, Inc. www.FormsWorkflow.com 9. Applicant agrees to immediately notify the department of any change in ownership, management, and if a corporation, any change in the officers/directors, and understands that failure to do so may result in immediate suspension of license. 10. Have you as an applicant, or any proprietor, partner, managing agent, director, officer, stockholder owning at least 20% corporation stock, if a limited liability company, any member owning at least 20% of the company, had a state alcoholic beverage license, permit, or agency revoked within the last three years?________ If so, please explain. ______________________________________________________________________________ ______________________________________________________________________________ 11. The undersigned verifies that proprietor/applicant is at least 21 years of age. 12. List the names, addresses and dates of birth of all employees of the business. Attach extra sheets if necessary. NAME ADDRESS BIRTH DATE ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 13. List any other alcoholic beverage licenses held by applicant: ______________________________________________________________________________ ______________________________________________________________________________ 14. Current Accounts Lists: List names, addresses, and products of all manufacturers, suppliers, and importers the applicant is authorized to represent. Attach extra sheets if necessary. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (The applicant agrees to maintain on file with the department a current accounts list, and agrees to notify the department in writing of any changes to the accounts listed within 14 days from the date the applicant either acquired or lost the account of a particular manufacturer, supplier, or importer.) 15. List locations where these products are stored in Utah other than the Department of Alcoholic Beverage Control: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 16. Does applicant hold a federal importer’s permit from the Alcohol and Tobacco Tax and Trade Bureau?______ If yes, submit a copy. 6.04.08 American LegalNet, Inc. www.FormsWorkflow.com 17. By signing below, the applicant attests that: a) neither he, nor any partner, managing agent, director, officer, shareholder owning at least 20% of corporation stock, or if a limited liability company, any member owning at least 20% of the company, has acquired or holds any interest in any retailer’s license issued under the Alcoholic Beverage Control Act (this does not apply if the license is held by a retailer that is completely owned by the applicant), or has acquired any interest in real or personal property owned, occupied, or used by any retailer licensed under the Act in the conduct of the retailer’s business (this does not apply if the retailer is completely owned by the applicant). b) consent is granted to representatives of the Alcoholic Beverage Control Department, Commission, State Bureau of Investigation (Bureau of Alcoholic Beverage Law Enforcement), and other law enforcement agencies to be admitted immediately and permitted without hindrance or delay to inspect the entire premises and all records of the licensee. c) he/she has read and will abide by the provisions of Title 32A, Utah Code, and all rules of the commission and directives of the Department of Alcoholic Beverage Control; and understands that failure to adhere thereto or to no longer possess the qualifications of a licensee may result in suspension or revocation of the liquor license and forfeiture of compliance bond. d) the applicant does not and will not discriminate against persons on the basis of race, color, sex, religion, ancestry, or national origin. f) as a condition of licensing employees or agents of the local industry representative licensee may not be the holder of any retail license issued under this title; or be employees or agents of any retail licensee issued under this title. g) he/she has read and understands the statements made herein, and that execution hereof is done voluntarily and by authorization of the applicant/organization, and that any false statement made on this application or any related document is a second degree felony. 18. The undersigned hereby makes application to the Utah Alcoholic Beverage Control Commission for a local industry representative license and certifies that the information contained herein and attached hereto is true and correct. STATE OF ________________________ Dated this_______day of______________, 20____ COUNTY OF_______________________ ___________________________________ Applicant’s Signature Subscribed & sworn to before me this _______ day of _________________, ________. ___________________________________ Print Name / Title _______________________________________ Notary Public SEAL: 6.04.08 American LegalNet, Inc. www.FormsWorkflow.com INFORMED CONSENT AND RELEASE OF LIABILITY PURPOSE: To determine, in accordance with Utah Code 32A-1-702 and 32A-1-703, if an applicant with the Department of Alcoholic Beverage Control has been: convicted of a felony under federal or state law; convicted of a violation of a federal law, state law, or local ordinance concerning the sale, manufacture, distribution, warehousing, or transportation of an alcoholic beverage; convicted of a crime involving moral turpitude; convicted on two or more occasions within the previous five years, driving under the influence of alcohol, a drug, or the combined influence of alcohol and a drug. RELEASE I hereby authorize the Department of Alcoholic Beverage Control (DABC) to investigate my criminal history records to ascertain any and all information which may be pertinent to my qualifications as an applicant with the DABC. The release of any and all information is authorized whether it is of record or not, and I do hereby release all persons, firms, agencies, companies, groups or installations, whomsoever, from any damages of or resulting from, furnishing such information to the DABC. I further agree that a copy of this release will remain in my application file. ______________________________________________________________________ Name (please print; last, first, middle initial) _______________________________ Formerly used last names (please print) _______________________________ Signature 6.04.08 _________________________________ Applicant/ doing business as _________________________________ Date American LegalNet, Inc. www.FormsWorkflow.com (suggested attestation/stipulation letter to the DABC for a third-party national criminal background check) Date: ________________________ To whom it may concern: I, _____________________________, attest: 1. That I have submitted to the DABC the necessary fingerprint card(s) required for the application and consented to the fingerprint criminal background check(s) by the F.B.I. 2. That I am not aware of any criminal conviction that would disqualify me from applying for and holding a Utah Department of Alcoholic Beverage Control license or permit. I stipulate that if an F.B.I. report shows a criminal conviction that would disqualify me from holding the license, permit, or package agency, I shall immediately surrender the license, permit, or package agency to the department. I am enclosing a national criminal history background report from a third party background check reporting service. _____________________________________ Signature _____________________________________ Name/Title 6.04.08 American LegalNet, Inc. www.FormsWorkflow.com