For Office Use Only Liquor Control Board Licensing and Regulation PO Box 43098 Olympia WA 98504-3098 www.liq.wa.gov 360/664-1600 FAX (360) 753-2710 Date Check No. Amount Rec’d Rec’d By License No. Application: Serve Employees or Guests $500 fee For a business that does not hold a liquor license to serve liquor without charge to employees or invited guests (WAC 314-38-010/050). ? The liquor must be served to employees or invited guests in specified hospitality or dining rooms (the general ? public cannot be allowed in these rooms while liquor is being served). ? The liquor cannot be sold in any manner, whether by scrip, donation, or contribution. No charge may be made ? to the guests for admission to the hospitality or dining rooms, or for any meals or services provided in the rooms. ? Liquor service cannot be advertised. ? ? A class 4 permit holder may serve liquor for no more than 24 hours during any week. ? ? The liquor must be purchased at retail. ? Name of Applying Business Type of Business Business Address (Street or Route, City, State, Zip Code) Inside city limits Mailing Address (if different than above): Outside city limits Phone No: ( ) Designated room(s) where liquor will be served Partners, Corporate Officers, or Limited Liability Company Members/Managers Name Birthdate Home Address (Street, Route, or PO Box, City, State, Zip Code) Social Security Number Home Telephone No. ( ) % owned Title Spouse Name Birthdate Social Security Number Name Birthdate Social Security Number Home Address (Street, Route, or PO Box, City, State, Zip Code) Home Telephone No. ( ) % owned Title Spouse Name Birthdate Social Security Number Name Birthdate Social Security Number Home Address (Street, Route, or PO Box, City, State, Zip Code) Spouse Name Home Telephone No. ( ) Birthdate % owned Title Social Security Number (attach additional sheets if necessary) I declare under the penalties of perjury that the answers contained in this application are true, correct, and complete. The undersigned certifies it is understood that a misrepresentation of fact is cause for rejection of this application or revocation of any permit issued. Applicant: Keep Pink Copy LIQ 651-51 5/00 American LegalNet, Inc. www.FormsWorkflow.com