State of Washington Business Licensing Service PO Box 9034 Olympia, WA 98507-9034 Telephone 1-800-451-7985 Limited Liability Company Information Must be filed with a Business License Application (or upon request) Type of license(s) requested. Check all that apply: Liquor Lottery A LLC information LLCs must be registered with the Washington Secretary of State Name of LLC LLC mailing address Street or route, PO box, city, state, zip code UBI number If known Date of formation State of formation Telephone number ( ) B LLC members/managers and spouses Title Member Manager Spouse of above Name Address/telephone number Birthdate Social Security number % or units owned Member Manager Spouse of above Member Manager Spouse of above Member Manager Spouse of above Please attach additional sheets if necessary, in same format C Certification The undersigned hereby certifies to the Washington State Liquor and Cannabis Board and Lottery Commission, that the above information is accurate and complete. Misrepresentation of this information is cause for denial of the license applied for. Print name of LLC member or manager Signature of LLC member or manager Title Date X For assistance or to request this document in an alternate format, please visit http://bls.dor.wa.gov/BLS or call 1-800-647-7706. Teletype (TTY) users may use the Washington Relay Service by calling 711. BLS-700-310 (8/4/15) American LegalNet, Inc. www.FormsWorkFlow.com