For Office Use Only Liquor Control Board Licensing and Regulation PO Box 43098 Olympia WA 98504-3098 www.liq.wa.gov FAX 360/753-2710 Date Check No. Amount Rec’d Rec’d by Application for Class 11 Permit Bed and Breakfast Facility - $75 Fee A class 11 permit allows a bed and breakfast lodging facility to donate or serve beer or wine without charge to overnight guests, for consumption on the premises. A bed and breakfast lodging facility is defined as a hotel or similar facility, offering from one to eight lodging units and breakfast to travelers or guests. Forms Needed: ? Application for Class 11 Permit with fee (check payable to WSLCB) ? Personal/Criminal History Statement for all applicants ? Proof of ownership or use of property (such as a lease or a purchase and sale agreement) Please call the Customer Service Desk if you have any questions, at (360) 664-1600. Applicant Information Applicant’s Name(s) (First, Middle, Last) Name of Corporation, Partnership, or Limited Liability Company (if applicable) Mailing Address (Street or PO Box, City, State, Zip Code) Telephone No. Contact Person ( ) Telephone No. Title ( ) Business Location Information Name of Business Telephone No. ( ) Type of Business (include how alcohol will be served, i.e., with breakfast, in room, etc.) Location Address (Street or Route, City, State, County, Zip Code) Inside City Limits? Yes No. of Rooms Available No I declare under the penalties of perjury and the revocation of any permit granted, that I am the applicant or the authorized representative of the person(s) or entity making this application. I declare that the answers contained, including any accompanying information, are true, correct, and complete. Signature Title Date LIQ 391-51 2/99 American LegalNet, Inc. www.FormsWorkflow.com