UTAH DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL 1625 South 900 West x PO Box 30408 x Salt Lake City, Utah x 84130-0408 (801) 977-6800 x Fax 977-6888 www.abc.utah.gov SPECIAL USE PERMIT (SCIENTIFIC & EDUCATIONAL) APPLICATION CHECKLIST Dear Applicant: The items below must be completed and submitted by the 10th of the month before any action can be taken by the Utah Alcoholic Beverage Control Commission. You will be notified of the next monthly commission meeting at which your application will be considered for issuance of a license. 1. Completed application (form enclosed). 2. Criminal history background check information (see application). 3. Local Consent from either city/town council if premises in incorporated area, or county commission if unincorporated area (form enclosed). 4. $100.00 initial fee (refundable if permit not granted). Make check payable to Utah Department of Alcoholic Beverage Control. Enclosed for your information are copies of the Utah Code and the Utah Department of Alcoholic Beverage Control Rules pertaining to Special Use permits. If you have any questions, please contact Licensing and Compliance at (801) 977-6800. 6.06.08 American LegalNet, Inc. www.FormsWorkflow.com UTAH DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL APPLICATION FOR SPECIAL USE PERMIT (Scientific & Educational) 1. Applicant/Organization: ____________________________________________________ 2. Business Name: ___________________________________________________________ 3. Address: ________________________________________________________________ Street PO Box City State Zip 4. Phone:__________________ Person to Contact________________________________ 5. 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 [] Applicant is a partnership: List below information for: (a) All Partners [] Applicant is a corporation: List below information for: (a) Any Stockholder owning at least 20% of the corporation (b) All Corporate officers and Directors [] Applicant is a limited liability company (LLC): List below information for: (a) Any members owning at least 20% of the company 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. 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. 6.06.08 American LegalNet, Inc. www.FormsWorkflow.com 6. Criminal History. The law prohibits persons who have been convicted of certain crimes from being in the alcoholic beverage business. This applies to any applicant, proprietor, partner, managing agent, director, or officer of the business. This also applies to any stockholder owning at least 20% of the corporation stock, or if a limited liability company, any member owning at least 20% of the company. Please list all criminal offenses other than minor traffic offenses of which you or any of these persons (including persons listed in subparagraph 5) 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 5. 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. at this web address: http://www.fbi.gov/hq/cjisd/pdf/fpcardb.pdf You may download the fingerprint card 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. 6.06.08 American LegalNet, Inc. www.FormsWorkflow.com 7. List the types of alcoholic products to be utilized and the purpose: ___________________________________________________________________________________ ___________________________________________________________________________________ 8. List the location for storage of alcoholic products:__________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 9. By signing below, the applicant attests that: a) the applicant is at least 21 years of age. 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 permit holder. c) he/she has read and will abide by the provisions of Section 32A-6, Utah Code and all rules and directives of the Utah Department of Alcoholic Beverage Control; and understands that failure to adhere thereto shall constitute grounds for removal of said permit. d) the applicant does not and will not discriminate against persons on the basis of race, color, sex, religion, ancestry, or national origin. e) he/she has read and understands the statements made herein; that execution thereof is done voluntarily and by authorization of said organization, and that any false statement made on this application or any related document is a second degree felony. 10. The undersigned hereby makes application to the Utah Alcoholic Beverage Control Commission for a Special Use (Scientific & Educational) permit and certifies that the information contained herein to be true and correct. Date: ___________________________ STATE OF ________________________ COUNTY OF_______________________ ________________________________ Applicant/owner of business ________________________________ Authorized signature ________________________________ Name/title Subscribed & sworn to before me this _______ day of ____________________, ________. _______________________________ Notary Public SEAL: 6.06.08 American LegalNet, Inc. www.FormsWorkflow.com LOCAL CONSENT SPECIAL USE PERMIT (Scientific & Educational) Date: ___________________________ Utah Department of Alcoholic Beverage Control Licensing and Compliance Section 1625 South 900 West PO Box 30408 Salt Lake City, Utah 84130 Gentlemen: ________________________________________________________ (City)(Town)(County) hereby grants its consent to the issuance of a Special Use permit to __________________________________________, Special Use permittee, located at____________________________________________, pursuant to the provisions of Section 32A-6, Utah Code for the purpose of purchase, storage and/or other lawful use of alcoholic products as authorized by the Utah Department of Alcoholic Beverage Control. Sincerely, ____________________________________ Authorized Signature ____________________________________ Name/Title 6.06.08 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) _________________________________ Applicant/ doing business as _______________________________ Signature _________________________________ Date 6.06.08 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 6.06.08 American LegalNet, Inc. www.FormsWorkflow.com