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Change In Corporate Officers And Or Stock Ownership Form. This is a Washington form and can be use in Liquor Control Board Statewide.
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Tags: Change In Corporate Officers And Or Stock Ownership, BLS-700-306, Washington Statewide, Liquor Control Board
UBI
MASTER LICENSE SERVICE
DEPARTMENT OF LICENSING
PO BOX 9048
OLYMPIA WA 98507-9048
PHONE: (360) 664-1400
Liquor/Lottery Lic. No. (Office Use Only)
www.dol.wa.gov
For Validation Only
CHANGE IN CORPORATE OFFICERS
AND/OR STOCK OWNERSHIP
01P-400-925-0003
List fee amount next to each license you hold and enter total fees due in the box below
AMOUNT DUE
TYPE OF LICENSE HELD/FEE
Liquor......... $75.00 Change in more than 10% of stock or election of new officers
$
Lottery........ $25.00 Change in 10% stock or more (no fee for corporate officer change).
$
Gambling.... $55.00 Change in stock of 10%-50% (no fee for corporate officer change).
Note: Contact the Gambling Commission if the change is greater than 50%. $
! Make check payable to the WASHINGTON STATE TREASURER.
TOTAL AMOUNT DUE
$
Note: Corporate officer changes should also be filed with the Washington Secretary of State.
CORPORATE INFORMATION
Corporate Name as registered with the Washington Secretary of State
Corporation Mailing Address: (Street or Route)
City
UBI No.
State
Zip Code
Telephone No.
(
Contact Name: (Last, First, Middle)
Contact Telephone No.
(
CORPORATE OFFICERS
PRESIDENT
VICE PRESIDENT
Birth Date
Home Address: (Street or Route)
City
State
Social Security No.
Zip Code
% Owned
Telephone No.
(
)
Name of Spouse: (Last, First, Middle)
Name: (Last, First, Middle)
Birth Date
Home Address: (Street or Route)
City
State
Social Security No.
Zip Code
% Owned
Telephone No.
(
)
Name of Spouse: (Last, First, Middle)
Name: ( Last, First, Middle)
SECRETARY
)
At the completion of this corporate change, the officers will be as follows:
Name: (Last, First, Middle)
Birth Date
Home Address: (Street or Route)
City
State
Social Security No.
Zip Code
% Owned
Telephone No.
(
)
Name of Spouse: (Last, First, Middle)
Name: ( Last, First, Middle)
TREASURER
)
Birth Date
Home Address: (Street or Route)
City
State
Social Security No.
Zip Code
% Owned
Telephone No.
(
)
Name of Spouse: (Last, First, Middle)
If necessary, attach additional sheets using the same format as shown above
Please continue on to the next page.
Your signature is required on page 2.
BLS-700-306 CHNG. CORP. OFC/STK OWN (R/2/04)OR/W Page 1 of 2
The Department of Licensing has a policy of providing equal access to its services. If
you need special accommodation, please call (360)664-1400 or TTY (360)664-8885.
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STOCK OWNERSHIP
Total Stock Authorized
Number of Shares Issued
Par Value per Share
LIST STOCKHOLDERS AND STOCK CERTIFICATES
Please complete all of the following. Start with certificate number 1. If more space is needed, attach additional sheets using the same format.
Name of Stockholder: (Last, First, Middle)
Social Security No.
Street or Route
Home Address:
Number of Shares Owned
% Owned
City
State
Zip Code
Social Security No.
Street or Route
Number of Shares Owned
% Owned
City
State
Zip Code
% Owned
City
State
Zip Code
% Owned
City
State
Zip Code
% Owned
City
State
Zip Code
% Owned
Name of Spouse: (Last, First, Middle)
Social Security No.
Street or Route
Number of Shares Owned
Birth Date
Date(s) Issued or Enter “Pending” if Not Yet Issued
Name of Stockholder: (Last, First, Middle)
Home Address:
Name of Spouse: (Last, First, Middle)
Social Security No.
Street or Route
Number of Shares Owned
Birth Date
Date(s) Issued or Enter “Pending” if Not Yet Issued
Name of Stockholder: (Last, First, Middle)
Home Address:
Name of Spouse: (Last, First, Middle)
Social Security No.
Street or Route
Number of Shares Owned
Birth Date
Date(s) Issued or Enter “Pending” if Not Yet Issued
Name of Stockholder: (Last, First, Middle)
Home Address:
Name of Spouse: (Last, First, Middle)
Social Security No.
Street or Route
Number of Shares Owned
Birth Date
Date(s) Issued or Enter “Pending” if Not Yet Issued
Name of Stockholder: (Last, First, Middle)
Home Address:
Name of Spouse: (Last, First, Middle)
Date(s) Issued or Enter “Pending” if Not Yet Issued
Name of Stockholder: (Last, First, Middle)
Home Address:
Birth Date
City
State
Zip Code
Birth Date
Name of Spouse: (Last, First, Middle)
Date(s) Issued or Enter “Pending” if Not Yet Issued
Please note: Additional forms or documents may be required by the individual agency
Liquor Control Board: (360)664-1600 • Lottery: (360)753-2155 • Gambling: (360)438-7654 ext. 300
CERTIFICATION
Under penalty of perjury, I hereby certify there have been no changes in officers or stockholders that have not been reported, and that
each officer and stockholder is the real party in interest with respect to his/her position and is not acting directly or indirectly as agent,
employee or representative of any other person not reported. The undersigned certifies on behalf of the corporation that it is understood
that a misrepresentation of fact is cause for rejection of this application or revocation of any license issued.
FOR GAMBLING ONLY: Elected Chief Executive must sign below.
Name (please print)
Signature
X
Title
Date
BLS-700-306 CHNG. CORP. OFC/STK OWN (R/2/04)OR/W Page 2 of 2
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