Licensing and Regulation PO Box 43085 Olympia, WA 98504-3085 Phone: 360-664-1600,Option 1,then Option 2 Fax: 360-664-4054 For Office Use Only Date: Check No.: Amount rec'd: Received by: http://lcb.wa.gov Application for Agent's License Application Processing Information 1. 2. 3. 4. 5. 6. The annual application fee is $27. Licenses expire June 30th each year. Please make your check payable to WSLCB and mail it to the above address. Please allow 14 business days for processing. Renewal letters are mailed approximately four to six weeks before the expiration date. Note: This form in used only for a new agent license. If you are renewing your agent's license, please use the Application for Renewal of Agent's License form available on the WSLCB website. If you have questions or need assistance, call (360) 664-1600, Option 1, then Option 2. To be Completed by the Applicant Company Full Legal Name of Company or Corporation Represented by Agent Company Address (Street or Route, City, State, Zip Code) Company License No. Telephone No. ( )Date of Birth SSN# Telephone No. ( )- To be Completed by Agent PRINT Agent's Name (First, Middle, Last) Agent's Business Address (if different from applicant company) Agent's E-mail address Do you hold any other job or engage in any other employment with or without pay? If Yes, please explain: Yes No Do you have any financial interest of any nature whatsoever in any business involved in the retail sale of beer, wine, or spirituous liquor? This includes lessor or landlord interests in a building, or as holder of a note, mortgage contract, or other forms of obligations or credit arrangements. Yes No If Yes, please explain: To be Completed by Applicant Company and Agent If this application is approved, we agree 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. Date: Agents' Signature Date: Company's Authorized Signature LIQ365 7/15 App for Agent Company's Authorized Printed Name American LegalNet, Inc. www.FormsWorkFlow.com LIQ365 7/15 App for Agent American LegalNet, Inc. www.FormsWorkFlow.com