Liquor Control Board Licensing and Regulatory Services PO Box 43098 Olympia WA 98504-3098 360/664-1616 www.liq.wa.gov For Office Use Only Date Check No. Amount Rec’d Rec’d By Application for Class 1, 2 or 6 Permit Type of Permit (Choose one) Class 1 Permit - $5 fee To purchase liquor (including alcohol) by a physician, dentist, a person in charge of an institution regularly conducted as a hospital or sanitarium, or a home devoted exclusively to the care of aged persons (RCW 66.20.010(1)). $ 5 fee to purchase 5 gallons or less Class 2 Permit $10 fee to purchase over 5 gallons To purchase alcohol by a person engaged in a mechanical or manufacturing business, or in scientific pursuits requiring alcohol (RCW 66.20.010(2). (There is no fee for city, county, state or federal institutions, or bona fide and accredited education institutions.) The use of alcohol for beverage purposes is prohibited. Class 6 Permit $5 fee To purchase liquor by a person operating a drug store, to be sold on the prescription of a physician (RCW 66.20.010(6). Name of Applying Business Name of Person Representing Business Type of Business Business Address (Street or Route, City, State, Zip Code) Mailing Address (if different than above): Phone No. ( ) (Street or Route, City, State, Zip Code) Specific purpose for which alcohol or liquor is to be used: Approximate amount of alcohol or liquor required for current fiscal year: I declare under the penalties of perjury that the answers contained in this application are true, correct, and complete. The undersigned certifies that it is understood that a misrepresentation of fact is cause for rejection of this application or revocation of any permit issued. Signature Title Date This document is published by the Washington State Liquor Control Board. Persons with a disability who need this document in an alternative format, or other accommodation to participate, may call (360) 664-1646 or the Liquor Control Board’s TTY at (360) 586-4727 or AT & T’s Relay Service at 1-800-833-6388. LIQ 354-50-10/03 American LegalNet, Inc. www.FormsWorkflow.com