State of Washington Business Licensing Service PO Box 9034 Olympia WA 98507-9034 1-800-451-7985 Master file number (For office use only) UBI number for Validation Only Application For Change of Limited Liability Company Member and/or Manager List fee amount next to each license you hold and enter total fees due in the TOTAL AMOUNT DUE box below: 03N-400-925-0003 Type of license held/fee Liquor............................ $75.00 Lottery .......................... $25.00 $ $ Amount due Note: Limited liability company changes should also be filed with the Washington Secretary of State. A Limited liability company information Name of limited liability company Company mailing address Street or route Contact name Last, first, middle City State Zip code UBI number Company telephone number ( Contact telephone number ( ) ( ) ) Company fax number B Member/manager information Name of member/manager Last, first, middle Member/manager #1 Home address Street or route Day telephone number ( ) Name of member's spouse Last, first, middle Name of member/manager Last, first, middle Member/manager #2 Home address Street or route Day telephone number ( ) Name of member's spouse Last, first, middle Name of member/manager Last, first, middle Member/manager #3 Home address Street or route Day telephone number ( ) Name of member's spouse Last, first, middle Evening telephone number ( ) Spouse social security number Spouse birthdate Month/day/year Evening telephone number ( ) Spouse social security number Social security number City State Spouse birthdate Month/day/year Birthdate Month/day/year Zip code Evening telephone number ( ) Spouse social security number Social security number City State Spouse birthdate Month/day/year Birthdate Month/day/year Zip code Social security number City State Birthdate Month/day/year Zip code Percentage of interest in business Percentage of interest in business Percentage of interest in business Attach additional sheets in the same format if necessary Under penalty of perjury, I hereby certify there have been no changes in members and/or managers that have not been reported, and that each member/manager is the real party of interest with respect to his/her position and is not acting directly or indirectly as an agent, employee, or representative of any other person not reported. The undersigned certifies on behalf of the company that it is understood a misrepresentation of fact is cause for rejection of this application or revocation of any license issued. Signature Title Date signed X Printed name for assistance or to request this document in an alternate format, visit http://business.wa.gov/BLS or call 1-800-451-7985. Teletype (TTY) users may call 360-705-6718. BLS-700-351 (5/23/11) American LegalNet, Inc. www.FormsWorkFlow.com