Liquor Control Board Licensing and Regulation PO Box 43098 Olympia WA 98504-3098 Phone: (360) 664-1600 Fax: (360) 753-2710 Tied House Statement – Retail Trade Name__________________________ License No.______________________ I understand under the provisions of RCW 66.28.010: • I have no financial interest, directly or indirectly, in any business that manufactures, imports or distributes alcoholic beverages. I have no ownership in any brewery, microbrewery, winery, distillery, or other liquor supplier. • I have no ownership, stock* or investment in any manufacturer, importer, or distributor of alcoholic beverages including any brewery, microbrewery, winery, distillery, or other liquor supplier. • No person, officer, investor, or entity with an ownership interest in the business I am licensing has any financial interest, directly or indirectly, in any manufacturer, importer, or distributor of alcoholic beverages, nor have they any ownership, stock* or investment in any brewery, microbrewery, winery, distributor, distillery, or liquor supplier. • I have not, nor has any officer, investor, or entity with an ownership interest in the business I am licensing received, directly or indirectly, any money, financial assistance, advertising, sponsorship or promotion fees from any manufacturer, importer or distributor, of alcoholic beverages. • I have not, nor has any officer, investor, or entity with an ownership interest in the business I am licensing entered into any oral or written advertising, promotion, or trademark agreement, arrangement or contract with any manufacturer, importer or distributor of alcoholic beverages prohibited by RCW 66.28.010. • No subsidiary, affiliated, or parent company of the business I am licensing has any financial interest in or receives any money from any manufacturer, importer, or distributor of alcoholic beverages, nor has any subsidiary, affiliated, or parent company of the business I am licensing entered into any oral, written, advertising, promotion or trademark agreement, arrangement, or contract with any manufacturer, importer, or distributor of alcoholic beverages that is prohibited by RCW 66.28.010. • I have not rented any real property from a landlord who manufactures, imports or distributes alcoholic beverages. If the business I am licensing will be a spirits, beer, wine restaurant it may be leased from and located on the premises of a licensed brewery, microbrewery, winery, or distillery • I understand the restrictions of RCW 66.28.010 remain in effect as long as I am a party of interest in a retailer of alcoholic beverages. *Unless the stock is held in a mutual or retirement fund in which I have no controlling or voting interest. By signing this form I acknowledge my understanding of the above and any violation of this statement is cause for denial of a license or revocation of any liquor licenses currently held. Print Name Title Signature of sole proprietor, partner, officer, stockholder, LLC member Date LIQ 186-50-6/04 American LegalNet, Inc. www.FormsWorkflow.com