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Licensing and Regulation PO Box 43098 Olympia WA 98504-3098 Phone (360) 664-1600 Fax (360) 753-2710 www.lcb.wa.gov Application to Change Entity Name for a: Check one of the following: Corporation Limited Liability Company Limited Liability Partnership Limited Partnership Trade Name This application does not apply to any other license or permit. In order for the Liquor and Cannabis Board to approve this request, an entity name change must first be registered with the Washington Secretary of State. The Secretary of State can be reached at 360-725-0377. If you have any questions, please call customer service at (360) 664 -1600 Current Liquor License No. Licensee Name(s) Mailing Address Phone No. ( ) Class of Liquor License UBI No. Current Corporate/LLC/LLP/LP/Trade Name Corporate/LLC/LLP/LP/Trade Name Applied for Print Name of Licensee or Designee Print Title of Licensee or Designee [Corporate President, Corporate Vice-President, Corporate LLC Member/ Manager, Partner, Sole Proprietor] Secretary, Corporate Treasurer, Signature of Licensee or Designee X Date LIQ 701 7/15 American LegalNet, Inc. www.FormsWorkFlow.com