STATE OF WEST VIRGINIA DEPARTMENT OF REVENUE ALCOHOL BEVERAGE CONTROL ADMINISTRATION 322 70th Street S. E. Charleston, WV 25304-2900 INSTRUCTIONS FOR COMPLETING SPECIAL LICENSE APPLICATION PACKET FOR FAIRS AND FESTIVALS Please read all instructions carefully. All questions are to be answered in full. Applicant’s accuracy and thoroughness in completing the application packet will assist us in processing the application and prevent unnecessary delays. Applicant must type or print all answers on all forms. Please find enclosed: 1. One (1) copy of Form ABCA-192SF&F, Application for Special Events Fair and Festival License. 2. One (1) copy of Form ABCA-194 Non-Intoxicating Beer Bond. Instructions: 1. All questions and/or descriptions must be answered. The application must be signed and notarized. 2. Applicant must indicate whether Beer and/or Wine will be sold at the event. (See Box A on Form ABCA-192SF&F) 3. County - Fill in the blank at the top of form denoting the county where the fair or festival is to be held. 4. Name of Event - Write in the name of the fair or festival. 5. Answer all remaining questions (2 - 8). If any question/description cannot be completed in the available space on the application, please submit additional pages as needed. Be sure to indicate on the additional pages which question you are answering (print name of event and name of applicant) on the additional pages. 6. License Fees - License fees must be paid by Certified Check, Cashier’s Check, or Money Order. Make checks payable to the West Virginia ABCA. A processing fee of twenty-four ($24.00) dollars must be included for each individual listed for Live Scan Finger Printing; provided: Live Scan Finger Printing has not been completed on aforementioned individuals for this fiscal year. 7. Bonds - Applicants must have a $1,000.00 Non-Intoxicating Beer Bond completed on the form provided by the ABCA. ABCA-Lic.IA.4a. American LegalNet, Inc. www.FormsWorkflow.com 8. Health Permit - Applicants must provide a Health Permit issued in the applicant’s name (if an association, limited liability, or corporation, the health permit must be in the association’s, corporation’s, or LLC’s name). 9. Sponsorship - The fair or festival must be sponsored or endorsed by the governing body of either the municipality or of the county wherein the fair or festival is to be conducted. The applicant must provide a letter from the aforementioned stating the dates the event has been approved to be held. 10. Map - The applicant must provide a map/drawing/photographs of the area in which alcoholic beverages are to be served at the fair or festival. 11. Instructions for Signing (must list title): a. If an individual, by owner. b. If a partnership, by each member of the partnership. c. If an association, by each member of the governing board. d. If a corporation, by all officers, or by other persons specifically authorized by corporate resolution which resolution must be enclosed. e. If limited liability company, by all members. f. Manager(s) must sign. Please Note: All areas where alcoholic beverages will be sold or consumed must be licensed. Applications must be completed correctly and all necessary paperwork included when mailed to the ABCA. Failure to do so may result in the application being delayed and/or returned to the applicant for the necessary corrections. Mail Completed Application, Fees, and Required Accompanying Forms To: West Virginia Alcohol Beverage Control Administration Attn: Licensing Department 322 70th Street S.E. Charleston, WV 25304-2900 If you have any questions or need assistance, please call the Administration at 1-800-6428208 or (304)558-2481 and ask for the Licensing Department. Check list of forms/papers to return to the ABCA Licensing Department: G G G G G G G Form ABCA-192SF&F Form ABCA-194, Non-Intoxicating Beer Bond License fee(s) and Live Scan fee(s) Health Permit Corporate, Association, or Limited Liability Company Forms Municipality or County letter of sponsorship or endorsement Map/drawing/photographs of the area to be licensed American LegalNet, Inc. www.FormsWorkflow.com ABCA-192SF&F WEST VIRGINIA ALCOHOL BEVERAGE CONTROL ADMINISTRATION Application for Special Events, Fair and Festival License Consumption “On Premise” Class A County:____________________. A. !SPECIAL EVENTS ! Beer . . . . . . . . . . . . . $250 Wine . . . . . . . . . . . . . $250 Tax ID#:____________________. 1. Name of Event:______________________________________________________________. 2. Name of Applicant(s):_________________________________________________________. 3. Applicants Mailing Address: __________________________________________________________________________ (Street/Route) (City) (State) (Zip Code) 4. Applicant’s Telephone Number:(____)_______________, Fax (____)_____________ Other (____)___________. 5. Description of the location of the event (street, reference landmark, etc.):________________ __________________________________________________________________________. 6. Dates of event ( month /day/year): (Event can not exceed ten (10) days). Start:______________ End:_________________ Operation days and times must be listed below (if all times are the same as the first day write same on following lines): 7. ________ Title Supply the Following Information About Owner(s) and/or Officer(s) and Manager(s): _______________________________________ Residence Address _____-____-______ Social Security# ___________________________________ Name _______________________________________ Residence Address _____-____-______ Social Security# ___________________________________ Name _______________________________________ Residence Address ___/___/____ Date of Birth _____-____-______ Social Security# ___________________________________ Name _______________________________________ Residence Address ___/___/____ Date of Birth ________ Title ___________________________________ Name ___/___/____ Date of Birth ________ Title _____-____-______ Social Security# ___/___/____ Date of Birth ________ Title _______________________________________ Residence Address ___/___/____ Date of Birth ________ Title ___________________________________ Name __________ Yrs. Resident of WV (_____)_____________ Telephone Number _____-____-______ Social Security# US Citizen __________ % ownership Y/N __________ % ownership Y/N __________ % ownership Y/N __________ % ownership Y/N __________ % ownership Y/N __________ Yrs. Resident of WV (_____)_____________ Telephone Number __________ Yrs. Resident of WV (_____)_____________ Telephone Number __________ Yrs. Resident of WV (_____)_____________ Telephone Number *IF NOT A US CITIZEN, PLEASE ATTACH A WRITTEN EXPLANATION OF WHEN AND WHERE NATURALIZED. __________ Yrs. Resident of WV (_____)_____________ Telephone Number American LegalNet, Inc. www.FormsWorkflow.com 8. Name Criminal History - The following is a record of all convicted arrests of the owners, officers, directors, or manager(s). (All applicants will be checked through the Security Division at the WV Lottery). (Attach additional pages if necessary). If there have been no arrests insert the word “none”. Date of Arrest Charge Disposition of Arrest Location of Court (County/State) The undersigned agree, if a license is issued as herein applied for, to comply at all times and observe all the provisions of West Virginia Code Chapter 11, Article 16 et seq., and Chapter 60, Articles 1 through 8 et seq., and all Federal and State Statutes and the rules and regulations promulgated by the Alcohol Beverage Control Administration. I or we certify under penalty of law and disqualification of licensure that all statements are true and complete. I or we release the State of West Virginia and any agent acting on its behalf from any and all liability by reason of the request for such information. American LegalNet, Inc. www.FormsWorkflow.com The undersigned hereby verify that we are all of the officers and all of the members of the board of directors of the applicant and that the statements and answers made in the foregoing application are true and the said writing is the act and deed of said Corporation, Limited Liability Company, Association, Individual, Partnership, Limited Partnership. (PRESIDENT, INDIVIDUAL, OR CONTROLLING MEMBER(S) SIGNATURE MUST BE NOTARIZED!) (MUST MATCH OFFICERS LISTED WITH THE SECRETARY OF STATE) (PRINT CLEARLY) (WRITTEN SIGNATURE REQUIRED) NAME: _____________________________________________ TITLE: _________________________________________ SIGNATURE:________________________________________ NAME: _____________________________________________ TITLE: _________________________________________ SIGNATURE:________________________________________ NAME: _____________________________________________ DATE OF SIGNATURE:______________ TITLE: _________________________________________ SIGNATURE:________________________________________ NAME: _____________________________________________ DATE OF SIGNATURE:______________ TITLE: _________________________________________ SIGNATURE:________________________________________ NAME: _____________________________________________ DATE OF SIGNATURE:______________ DATE OF SIGNATURE:______________ TITLE: _________________________________________ SIGNATURE:________________________________________ DATE OF SIGNATURE:______________ * (MUST HAVE MANAGER(S) SIGNATURE) State of West Virginia, _________________________________________________________ County, To-Wit: _________________________________________________________________________, Being first duly sworn according to law, deposes and says that he/she is_____________________________________________________ President, Individual, or Controlling Member(s) of the ____________________________________, authorized by law to do business in the State of West Virginia, and that the statements and answers made in the foregoing application are true and acknowledge the said writing to be the act and deed of said corporation. (Applicant Signature)________________________________ STATE OF WEST VIRGINIA, COUNTY OF______________________________, to wit: Sworn to before me and subscribed in my presence this ________ day of_______________, __________________ __________________________________________ NOTARY PUBLIC My Commission Expires _________________________________ Seal of Notary American LegalNet, Inc. www.FormsWorkflow.com ABCA - 194 For Fiscal Year _________ to ___________ Surety Bond #:_________________ NONINTOXICATING BEER BOND THIS BOND MAY BE USED BY AN INDIVIDUAL, PARTNERSHIP, ASSOCIATION OR CORPORATION KNOW ALL MEN BY THESE PRESENTS: That (I) (we), If individual or partnership insert name of people Corporation or association insert name of corporation or association being Insert one above An Individual, Partnership, Corporation, or Association doing business under the name of / / (County) (Mailing Address) (City) West Virginia, as principal, and a corporation authorized (Name of corporate surety) to do business in the State of West Virginia, as surety, are held and firmly bound unto the STATE OF WEST VIRGINIA in the full and just sum of One Thousand Dollars ($1,000.00), to the payment whereof well and truly to be made, we bind ourselves, our successors and assigns, jointly and severally, firmly by these presents. THE CONDITION of the above obligation is such that whereas the above bound principal is about to obtain a license in pursuance of the provisions of: Article 16, Chapter 11 of the Code of West Virginia, of 1931, as amended, and regulations promulgated thereunder by the Commissioner, a CLASS A RETAIL DEALER'S LICENSE to sell nonintoxicating beer on the premises described in the application for such license. NOW, THEREFORE, if the said principal shall faithfully observe the laws of the State of West Virginia, and regulations promulgated thereunder by the Commissioner, with respect to the distribution, sale and dispensing of nonintoxicating beer, then this obligation to be void; otherwise to remain in full force and effect, and if the license of said principal shall be revoked, then the full amount of this bond shall be forfeited to the State of West Virginia, and said amount when received by the State shall be credited to the state fund, general revenue. This bond is executed in pursuance of the provisions of said Article 16, Chapter 11 of the Code of West Virginia, of 1931, as amended, and regulations promulgated thereunder by the Commissioner, and the pertinent provisions of said articles and regulations are hereby made a part of this bond. INDIVIDUAL OR PARTNERSHIP APPLICANTS EXECUTE BELOW IN WITNESS WHEREOF, the said principal(s) (has) (have) hereunto set (his) (their) hand and seal(s), and the said surety has caused its corporate name to be signed hereto and its corporate seal to be hereunto affixed by its official or agent there unto duly authorized, and this bond is to be effective from the ________ day of , , to the 30th day of June, _________, unless sooner released by the State of West Virginia or cancelled by the surety after due notice to all parties concerned. day of Signed and dated this , (All Partners Must Sign As Principal) Principal: Surety: (Seal) Address: (Seal) (Seal) By: Title (SURETY CORPORATE SEAL) (Seal) CORPORATE OR ASSOCIATION APPLICANTS EXECUTE BELOW IN WITNESS WHEREOF, the (said corporate principal) (said association principal) and the said surety have caused their respective names to be signed hereto and their respective seals to be hereunto affixed by their respective officials or agents thereunto authorized, and this bond is to be effective from the day of , , to the 30th day of June _______,unless sooner released by the State of West Virginia or cancelled by the surety after due notice to all parties concerned. Signed and dated this day of , Surety: INSTRUCTIONS FOR SIGNING If Association or Fraternal Club has two owners, all must sign bond as Association principals. If ownership involves more than two persons, one officer or (owner) can be Address: (Seal) By: Its: (SURETY CORPORATE SEAL) empowered to sign on behalf of Association. Corporation must be signed by President (Title) or Vice-President. If any other officer signs, attach corporate resolution or Power of Attorney permitting him to bind corporation. Association (Seal) Resident Agent:__________________________________ Address:________________________________________ ________________________________________ Phone No:______________________________________ (Seal) (Seal) Principals: (Seal) Corporate Name: By: American LegalNet, Inc. www.FormsWorkflow.com (Seal) Its: Title Note: No. 1 -To be completed by Notary Public for an Individual or Partnership. No. 2 -To be completed by Notary Public for a Corporation or an Association. No. 3 -To be completed by Notary Public for Bonding Company Signature. Power of Attorney should be attached and dated, notarized same day as issuance of bond. NO. 1 - INDIVIDUAL OR PARTNERSHIP ACKNOWLEDGMENT STATE OF WEST VIRGINIA, COUNTY OF _______________________________, To-wit: I,_________________________ , a Notary Public in and for the county and state aforesaid, do hereby certify that ________________________________,whose name(s) (is) (are) signed to the writing above or hereto annexed, bearing date on the ______ day of __________ , ______, (has) (have) this day acknowledged the same before me in my said county. Given under my hand this _______ day of _________________ , ______. _____________________________________________________________ Notary Public My Commission expires on the _______ day of _______________, _____. NO. 2- CORPORATION OR ASSOCIATION ACKNOWLEDGMENT STATE OF WEST VIRGINIA, COUNTY OF ______________________________, To-wit: I, ________________________ , a Notary Public in and for the county and state aforesaid, do hereby certify that _________________________________, who signed the writing above, or hereto annexed, for ___________________,(a corporation) (an association), bearing date on the ______ day of ______________ , ________ , (has) (have) this day in my said county, before me, acknowledged the said writing to be the act and deed of said (corporation) (association). Given under my hand this ______ day of _________________ , ________. ______________________________________________________________ Notary Public My commission expires on the ______ day of __________________ , _______. NO. 3-BONDING COMPANY - CORPORATE ACKNOWLEDGMENT (For Individual Signing For Surety) STATE OF WEST VIRGINIA, COUNTY OF ________________________________, To-wit: I, ___________________________ , a Notary Public in and for the county and state aforesaid, do hereby certify that _______________________________ , who signed to the writing above, or hereto annexed for ___________________ , a corporation, bearing date on the _______ day of ___________ , ______, (has) (have) this day in my said county, before me, acknowledged the said writing to be the act and deed of said corporation. Given under my hand this _______ day of ____________________, _______. ______________________________________________________________ Notary Public My commission expires on the _______ day of __________________, ______. American LegalNet, Inc. www.FormsWorkflow.com West Virginia Alcohol Beverage Control Administration Floor Plan License period: _____-_____ Applicant Entity Name: Doing Business As (DBA) Name: County: Floor plan must include all areas under the control or lease of the applicant where alcohol is to be stored, sold or consumed. All areas under control or lease of the licensee must be licensed. Submit (1) copy to ABCA. (Give Dimensions) Keep (1) copy at licensed premises. *If there are attached drawings please check: ______ (additional drawings must be signed). *Complete information on reverse side of form. (Addendum A) ABCA-Lic.FP.3 American LegalNet, Inc. www.FormsWorkflow.com Room or Outside Structure (Width, Length)(example: 24' X 36') Seating Capacity Located on What Floor Location (serving, kitchen, storage, etc...) I or we hereby certify that the floor plan above and/or attached is the only area where alcoholic beverages will be sold, dispensed, consumed, and/or stored. And, I or we further understand that any violation of this provision will mean immediate revocation or suspension of my license. Signature:________________________________________ Title: Date: Signature:________________________________________ Title: Date: Signature:________________________________________ Title: Date: Signature:________________________________________ Title: Date: Signature:________________________________________ Title: Date: American LegalNet, Inc. www.FormsWorkflow.com Applicant/Entity Name:________________________________________________________ Doing Business As (DBA) Name:______________________________________ WEST VIRGINIA ALCOHOL BEVERAGE CONTROL ADMINISTRATION RELEASE OF INFORMATION AND WAIVER OF CONFIDENTIALITY OF RECORDS I or we, having made application with the West Virginia Alcohol Beverage Control Administration for issuance of a license to sell alcoholic beverages within the State of West Virginia, hereby waive the benefit of any municipal, county, state, or federal statute, rule, ordinance, regulation or other law prescribing the confidentiality of any records or documents, whether formal or informal, pending or closed, maintained by any public or private agency or organization as those records or documents pertain to residency, business location, business activities, education and/or training, employment, criminal history, civil litigation, or law enforcement investigation. I or we, hereby authorize and request every public or private agency, organization, or person maintaining such records to furnish to the West Virginia Alcohol Beverage Control Administration, or their agents or representatives, any information contained therein and to permit them to inspect and make copies of such records and documents. I or we, hereby authorize the West Virginia Alcohol Beverage Control Administration to disclose any information pertaining to the licensure to any municipal, county, state, federal or private agency or organization that has any interest in the licensing of said applicant. I or we, hereby release the West Virginia Alcohol Beverage Control Administration, their agents and representatives, and any agency, organization, or person furnishing information from all liability arising out of any investigation concerning the applicant. I or we further agree that a copy of this Release and Waiver shall function as an original. I or we acknowledge that by affixing a signature(s) below gives this document full force, and upon this date all aforementioned information may be received and shared as prescribed. Name (Must include owner’s, officer’s, member’s and manager’s printed and written signature(s).) Title Date (Addendum B) ABCA-Lic.RIWCR.2 American LegalNet, Inc. www.FormsWorkflow.com