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. American LegalNet, Inc. www.FormsWorkflow.com