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. American LegalNet, Inc. www.FormsWorkflow.com 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 American LegalNet, Inc. www.FormsWorkflow.com