Liquor Control Board Licensing and Regulation PO Box 43098 Olympia WA 98504-3098 Phone: (360) 664-1600 Fax: (360) 753-2710 Tied House Statement For Publicly Traded Entities Trade Name__________________________ License No.______________________ • I understand that under the provisions of RCW 66.28.010, I shall have no financial interest, directly or indirectly, in any manufacturer, distributor, or importer of alcoholic beverages. This includes ownership in any company within the organizational structure of all breweries, wineries, distributors and/or liquor manufacturers. • I understand the restriction of RCW 66.28.010 remains in effect as long as I am an officer/party of interest in a liquor licensed business. By signing this form I acknowledge my understanding of the above and that any violation of this statement is cause for denial of a license or revocation of any liquor licenses currently held. ________________________________________ Print Name ________________________________________ Signature of partner, officer, stockholder, LLC member or manager LIQ 800-50-10/02 __________________ Date American LegalNet, Inc. www.FormsWorkflow.com