Licensing and Regulation PO Box 43098 Olympia WA 98504-3098 See Us on the Web: www.liq.wa.gov (360) 664-1600 Fax: (360) 753-2710 Liquor Control Board Addendum - Club This form must accompany a Master Application from the Department of Licensing, Master License Service. Club licenses are issued to bona fide nonprofit organizations, with liquor sales being incidental to the main purposes of the club. The organization must have operated for at least one year immediately prior to this application. For more information, please see the “Club Liquor License Information Sheet.” Questions? Please call the Liquor Control Board customer service desk at (360) 664-1600. Applicant Information Name of Organization Premises address: Street City State Zip Code Organization Information When was the organization formed? Is this a nonprofit organization, registered with the Washington Secretary of State? yes no Secretary of State File No. Purpose of the organization Patriotic / Fraternal Benevolent / Is the club part of a nationally chartered organization? LIQ 101-51 2/99 (s:RegSvcs/forms/LIQ10151 club addend) Yes Educational / Athletic / Social No Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Officer Information Name of Officer / Director Title Date of Birth Social Security No. Membership Information No. of registered members: No. of members under 21: Name of Membership Classification No. of Members in Classification Initiation Fee Annual Dues State Zip Code Facility Information Name of person responsible for day-to-day operations: Home Address: Street City Day Telephone No: Evening Telephone No: Check any of the following facilities your club offers its membership: Cocktail Lounge Dining Room Lodge Room Golf Course Game Room Athletic Facility Others Which, if any, departments or facilities of your organization are operated on a concession basis? LIQ 101-51 2/99 (s:RegSvcs/forms/LIQ10151 club addend) Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com Signature/Title LIQ 101-51 2/99 (s:RegSvcs/forms/LIQ10151 club addend) Date Phone Number Page 3 of 2 American LegalNet, Inc. www.FormsWorkflow.com