SCHEDULE FOR APPOINTMENT OF AGENT BY CORPORATION/NONPROFIT ORGANIZATION OR LIMITED LIABILITY COMPANY Submit to municipal clerk. All corporations/organizations or limited liability companies applying for a license to sell fermented malt beverages and/or intoxicating liquor must appoint an agent. The following questions must be answered by the agent. The appointment must be signed by the officer(s) of the corporation/organization or members/managers of a limited liability company and the recommendation made by the proper local official. Town To the governing body of: Village County of of City The undersigned duly authorized officer(s)/members/managers of (registered name of corporation/organization or limited liability company) a corporation/organization or limited liability company making application for an alcohol beverage license for a premises known as (trade name) located at appoints (name of appointed agent) (home address of appointed agent) to act for the corporation/organization/limited liability company with full authority and control of the premises and of all business relative to alcohol beverages conducted therein. Is applicant agent presently acting in that capacity or requesting approval for any corporation/ organization/limited liability company having or applying for a beer and/or liquor license for any other location in Wisconsin? Yes No If so, indicate the corporate name(s)/limited liability company(ies) and municipality(ies). Is applicant agent subject to completion of the responsible beverage server training course? Yes No How long immediately prior to making this application has the applicant agent resided continuously in Wisconsin? Place of residence last year For: (name of corporation/organization/limited liability company) By: (signature of Officer/Member/Manager) And: (signature of Officer/Member/Manager) ACCEPTANCE BY AGENT I, , hereby accept this appointment as agent for the (print/type agent’s name) corporation/organization/limited liability company and assume full responsibility for the conduct of all business relative to alcohol beverages conducted on the premises for the corporation/organization/limited liability company. Agent’s age (signature of agent) (date) Date of birth (home address of agent) APPROVAL OF AGENT BY MUNICIPAL AUTHORITY (Clerk cannot sign on behalf of Municipal Official) I hereby certify that I have checked municipal and state criminal records. To the best of my knowledge, with the available information, the character, record and reputation are satisfactory and I have no objection to the agent appointed. Approved on by (date) AT-104 (R. 4-09) (signature of proper local official) Title (town chair, village president, police chief) Wisconsin Department of Revenue American LegalNet, Inc. www.FormsWorkflow.com