RENEWAL ALCOHOL BEVERAGE LICENSE APPLICATION Applicant’s Wisconsin Seller’s Permit Number: Federal Employer Identification Number (FEIN): Submit to municipal clerk. Read instructions on reverse side. For the license period beginning: ending: (MM DD YYYY) TO THE GOVERNING BODY of the: County of CHECK ONE Town of Village of City of LICENSE REQUESTED (MM DD YYYY) } Aldermanic Dist. No. Individual Partnership Corporation/Nonprofit Organization (if required by ordinance) Limited Liability Company Complete A or B. All must complete C. TYPE FEE Class A beer Class B beer Class C wine Class A liquor Class B liquor Reserve Class B liquor   Publication fee $ $ $ $ $ $ $ TOTAL FEE $ A. Individual or Partnership: Full Name(s) (Last, First and Middle Name) Home Address Post Office & Zip Code B. Full Name of Corporation/Nonprofit Organization/Limited Liability Company Address of Corporation/Limited Liability Company (if different from licensed premises) All Officer(s) Director(s) and Agent of Corporation and Members/Managers and Agent of Limited Liability Company: Title Name (Inc. Middle Name) Home Address President/Member Vice President/Member Secretary/Member Treasurer/Member Agent Directors/Managers C. 1. Trade Name 2. Address of Premises Post Office & Zip Code Business Phone Number Post Office & Zip Code 3. Does the applicant understand that they must purchase alcohol beverages only from Wisconsin wholesalers?. . . . . . . . . . . . . . . . Yes 4. Premises description: Describe building or buildings where alcohol beverages are to be sold and stored. The applicant must include all rooms including living quarters, if used, for the sales, service, and/or storage of alcohol beverages and records. (Alcohol beverages may be sold and stored only on the premises described.) No 5. Legal description (omit if street address is given above): 6. a. Since filing of the last application, has the named licensee, any member of a partnership licensee, or any member, officer, director, manager or agent for either a limited liability company licensee, corporation licensee, or nonprofit organization licensee been convicted of any offenses (excluding traffic offenses not related to alcohol) for violation of any federal laws, any Wisconsin laws, any laws of other states, or ordinances of any county or municipality? If yes, complete reverse side . . Yes No b. Are charges for any offenses presently pending (excluding traffic offenses not related to alcohol) against the named licensee or any other persons affiliated with this license? If yes, explain fully on reverse side . . . . . . . . . . . . . . . . . . . . . . . . Yes No 7. Except for questions 6a and 6b, have there been any changes in the answers to the questions as submitted by you on your last application for this license? If yes, explain. No Yes 8. Was the profit or loss from the sale of alcohol beverages for the previous year reported on the Wisconsin Income or Franchise Tax return of the licensee? If not, explain. Yes No 9. Does the applicant understand a Wisconsin Seller’s Permit must be applied for and issued in the same name as that shown under Section A or B above? [phone (608) 266-2776] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 10. Does the applicant understand that alcohol beverage invoices must be kept at the licensed premises for 2 years from the date of invoice and made available for inspection by law enforcement? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 11. Is the applicant indebted to any wholesaler beyond 15 days for beer or 30 days for liquor?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No READ CAREFULLY BEFORE SIGNING: Under penalty provided by law, the applicant states that each of the above questions has been truthfully answered to the best of the knowledge of the signers. Signers agree to operate this business according to law and that the rights and responsibilities conferred by the license(s), if granted, will not be assigned to another. (Individual applicants and each member of a partnership applicant must sign; corporate officer(s), members/managers of Limited Liability Companies must sign.) SUBSCRIBED AND SWORN TO BEFORE ME this day of , 20 (Clerk/Notary Publc) (Officer of Corporation/Member/Manager of Limited Liability Company /Partner/Individual) (Officer of Corporation/Member/Manager of Limited Liability Company /Partner) My commission expires (Additional Partner(s)/Member/Manager of Limited Liability Company if Any) TO BE COMPLETED BY CLERK Date received and filed with municipal clerk Date reported to council/board Date license granted License number issued Date license issued Signature of Clerk / Deputy Clerk AT-115 (R. 8-11) Wisconsin Department of Revenue American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR RENEWAL ALCOHOL BEVERAGE LICENSE APPLICATION (AT-115) THIS RENEWAL FORM CANNOT BE USED IF: 1. There is a change in business entity (i.e., individual has changed to partnership or corporation/limited liability company; partnership changed to individual or corporation/limited liability company; corporation changed to individual, partnership or limited liability company) and if limited liability company has been dissolved. 2. Partners are added or dropped. 3. Application is made in a different municipality. PARTNERSHIPS: Indicate full name and home address of each partner. Each partner must sign application. Reminder: If partners have been added or dropped since your last application, you must use Form AT-106 (Original Beverage License Application). CORPORATIONS: The Officer(s) must sign application. Be sure to answer Question No. 7 by indicating any change of officers, directors, and/or changes in home address. If there are any changes in officers and/or directors each must complete Form AT-103 (Auxiliary Questionnaire). If there has been a change in agent since your last approved agent, he/she must complete Forms AT-104 (Schedule for Appointment of Agent) AND AT-103 (Auxiliary Questionnaire) in addition to this (AT-115) form. LIMITED LIABILITY COMPANY: Members/managers must sign application. Follow procedure under Corporations for any change of members or agent. NOTE: Application must be signed where indicated on all copies in the presence of a notary public. Use ink or typewriter when filling in applications. Be sure to answer all questions fully and accurately. Any lack of access to any portion of a licensed premises during inspection will be deemed a refusal to permit inspection. Such refusal is a misdemeanor and grounds for revocation of this license. DISCRIMINATION CLAUSE - (City of Milwaukee only) The applicant shall not willfully refuse to provide those services offered under this license or refuse to employ or discharge any person otherwise qualified because of race, color, creed, sex, national origin or ancestry, the applicant shall not seek information as a condition of employment, or penalize any employee or discriminate in the selection of personnel for training or promotion solely on the basis of such information. The applicant also shall not discriminate against any member of the military service dressed in uniform by willfully refusing services offered under this license. Complete, sign and return this form to the clerk. If answer to Questions No. 6a and/or 6b on reverse side are “YES,” outline details below: CONVICTIONS 1. NAME STATUTE NO./LOCAL ORDINANCE CHARGE WHERE CONVICTED DATE PENALTY 2. NAME CHARGE DATE MISDEMEANOR FELONY MISDEMEANOR FELONY WHERE CONVICTED FELONY STATUTE NO./LOCAL ORDINANCE MISDEMEANOR PENALTY 3. NAME STATUTE NO./LOCAL ORDINANCE CHARGE WHERE CONVICTED DATE PENALTY PENDING CHARGE 1. NAME STATUTE NO./LOCAL ORDINANCE DATE PENDING CHARGE American LegalNet, Inc. www.FormsWorkFlow.com