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 licences | 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 | |
