Questionnaire for Liquor License Application
No. |
Question |
Response |
1 |
Type of Transaction – Mark all that apply |
New License Transfer of License Change of Manager Transfer of Stock New Officer / Director Change of Location Alter Premises Pledge of License to Lender/Creditor Pledge of Stock to Lender/Creditor Other (Please specify) |
2 |
Name of Licensee – Official Name |
|
3 |
Name, Address, Date of Birth, Social Security Number & Phone Number for each Officers, Directors & Shareholders, with # of shares, of Licensee Entity |
President Treasurer Clerk Director(s) Shareholder(s) |
4 |
Are All Officers, Directors & Shareholders United States Citizens |
Yes No |
5 |
If No, specify citizenship |
|
6 |
Number of Shares Authorized |
|
7 |
Number of Shares Issued |
|
8 |
Name of Business – DBA Name |
|
9 |
Federal Identification Number |
|
10 |
Local Address of Licensee |
|
11 |
License Class – Annual or Seasonal |
|
12 |
License Category – Mark all that apply |
All Alcohol Wine & Malt Malt Only Wine Only Wine & Malt w/ Cordials Permit |
13 |
Type of License – Mark all that apply |
Club General on Premise Innholder Package Store Restaurant Tavern Veterans Club Other (Please specify) |
14 |
Phone number at Premise |
|
15 |
Seating Capacity of Premises |
|
16 |
Occupancy Number of Premises |
|
17 |
Will there be construction, remodeling, redecorating or building on the Premises for the License |
Yes No |
18 |
If Yes, give exact description of construction, remodeling, redecorating or building to be completed, including estimated costs, construction schedule & source of construction financing |
|
19 |
Will Premises be Owned |
Yes No |
20 |
If Yes, provide name of owning entity |
|
21 |
If No, provide Landlord info including |
Name Phone Number Address Date of Birth Social Security Number Rent Amount Dates of Lease |
22 |
Are assets being purchased |
Yes No |
23 |
If Yes, provide Purchase Price & copy of Purchase & Sale Agreement |
Equipment Inventory Furniture License Goodwill Premises |
24 |
Identify Source of Financing and provide evidence of source |
Mortgage Cash Seller Other (Please specify) |
25 |
Will inventory be pledged |
Yes No |
26 |
If Yes, to whom |
|
27 |
Will license be pledged |
Yes No |
28 |
If Yes, to whom |
|
29 |
Will corporate stock be pledged |
Yes No |
30 |
If Yes, to whom & how many shares |
|
31 |
Do you have or have you had any other licenses |
Yes No |
32 |
If Yes, please provide |
Type of License Licensee Name and Address Date Ownership Terminated Reason for Termination Provide copies of any and all action with City/Town Licensing Board & ABCC |
33 |
Name of Transferring Entity |
|
34 |
Name and Address for each Officers, Directors & Shareholders, with # of shares, of Transferring Entity |
President Treasurer Clerk Director(s) Shareholder(s) |
35 |
Name of On-Premises Manager |
|
36 |
Social Security Number of On-Premises Manager |
|
37 |
Home Address of On-Premises Manager |
|
38 |
Telephone Number of On-Premises Manager |
Home Work |
39 |
Place of Birth of On-Premises Manager |
|
40 |
Date of Birth of On-Premises Manager |
|
41 |
Is On-Premises Manager a Registered Voter – Mark answer that applies |
Yes No |
42 |
Is On-Premises Manager a U.S. Citizen – Mark answer that applies |
Yes No |
43 |
If No, provide Naturalization information |
Court Date Proof of Citizenship |
44 |
Father’s Name |
|
45 |
Mother’s Name (w/ Maiden Name) |
|
46 |
Does On-Premises Manager have a Criminal Record |
Yes No |
47 |
If Yes, Please explain |
Describe Offense Specific Charge Disposition |
48 |
Does On-Premises Manager have prior experience in Liquor Industry |
Yes No |
49 |
If Yes, Please explain in detail |
|
50 |
Does On-Premises Manager have a financial interest, direct or indirect, in any other liquor license, permit or certificate |
Yes No |
51 |
If Yes, please explain in detail |
|
52 |
Please list On-Premises Manager Employment for last Ten (10) Years |
Include: Dates Position Employer Address Telephone Numbers (if known) |
53 |
Approx Hours per week On-Premises Manager will spend on Premises |