For Office Use Only Regulatory Services Division PO Box 43098 Olympia WA 98504-3098 Phone: 664-1600 (Option 4) Fax: (360) 664-4054 Date: Check No. Amount Rec’d Rec’d By Application for Agent’s License $25 Fee Agent’s Licenses Expire June 30th To Be Completed by Applicant Company Full Legal Name of Company or Corporation Represented by Agent License No. of Company Address (City, State, Zip Code) Telephone No. To Be Completed by Agent Agent’s Name (First, Middle, Last) Please print Date of Birth Social Security No. Agent’s Business Address (if different from applicant company) Telephone No. ( Do you hold any other job or engage in any other employment with or without pay? ) yes no If yes, explain: Do you have any financial interest of any nature whatsoever in any business involved in the retail sale of beer, wine, or spirituous liquor (including lessor or landlord interests in building; or being a holder of a note, mortgage contract, or other forms of obligations or credit arrangements)? yes no If yes, explain and give details of t( ) To Be Completed by Applicant Company and Agent In making this application we agree, if application is approved, to abide by the provisions of the Washington State liquor laws and regulations, with particular reference to RCW 66.24.310, WAC 314-44-005, and WAC 314-12-140. We understand a misrepresentation of fact shall be deemed a lack of good faith and shall constitute good and sufficient cause for disapproval, revocation, or suspension of the license. Agent’s Signature Date Company Authorized Signature Date If you have any questions or need assistance, please call (360) 664-1617 LIQ 365-50-5/04 American LegalNet, Inc. www.FormsWorkflow.com