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Change Of Limited Liabilty Company Member And Or Manager Form. This is a Washington form and can be use in Liquor Control Board Statewide.
Tags: Change Of Limited Liabilty Company Member And Or Manager, BLS-700-351, Washington Statewide, Liquor Control Board
MASTER LICENSE SERVICE
DEPARTMENT OF LICENSING
PO BOX 9048
OLYMPIA WA 98507-9048
Telephone (360) 664-1400
www.dol.wa.gov
APPLICATION FOR:
Master File No. (For Office Use Only)
UBI No.
FOR VALIDATION
CHANGE OF LIMITED LIABILITY COMPANY
MEMBER AND/OR MANAGER
01P-400-925-0003
List fee amount next to each license you hold and enter total fees due in the TOTAL AMOUNT DUE box below:
TYPE OF LICENSE HELD/FEE
AMOUNT DUE
Liquor.............$75.00
$
Lottery............$25.00
$
! Make check payable to the WASHINGTON STATE TREASURER.
TOTAL AMOUNT DUE
$
Note: Limited Liability Company changes should also be filed with the Washington Secretary of State.
LIMITED LIABILITY COMPANY INFORMATION
Name of Limited Liability Company:
UBI No.
Company Mailing Address: Street or Route
City
State
Zip Code
Company Telephone No.
(
)
Contact Telephone No.
Company Fax No.
(
Contact Name: (Last, First, Middle)
(
)
)
MEMBER/MANAGER INFORMATION
Member/Manager #1
Name of Member/Manager: (Last, First, Middle)
Social Security No.
Home Address: (Street or Route)
City
Day Telephone No.
Evening Telephone No.
(
(
)
Member/Manager #2
State
Name of Member’s Spouse: (Last, First, Middle)
Percentage of Interest in Business
Spouse Social Security No.
Home Address: (Street or Route)
City
Spouse Birth Date Month/Day/Year
Social Security No.
Day Telephone No.
Evening Telephone No.
(
(
)
Birth Date Month/Day/Year
State
Percentage of Interest in Business
Spouse Social Security No.
Name of Member/Manager: (Last, First, Middle)
Home Address: (Street or Route)
City
Spouse Birth Date Month/Day/Year
Social Security No.
Day Telephone No.
Evening Telephone No.
(
(
Name of Member’s Spouse: (Last, First, Middle)
Zip Code
)
Name of Member’s Spouse: (Last, First, Middle)
)
Zip Code
)
Name of Member/Manager: (Last, First, Middle)
Member/Manager #3
Birth Date Month/Day/Year
Birth Date Month/Day/Year
State
Zip Code
Percentage of Interest in Business
)
Spouse Social Security No.
Spouse Birth Date Month/Day/Year
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.
Name (please print)
Title
X
Signature
BLS-700-351 CHNG IN LLC MGR (R/01/04)FM Page 1 of 1
Date
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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