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Augusta-Richmond County 1815 Marvin Griffin Road Augusta, GA 30906 ALCOHOL BEVERAGE APPLICATION Alcohol Number Year Alcohol Account Number 1. Name of Business 2. Business Address 3. City State Zip 4. Business Phone ( ) Home Phone ( ) 5. Applicant Name and Address: 6. Applicant Social Security # D.O.B. 7. If Application is a transfer, list previous Applicant: 8. Business Location: Map & Parcel Zoning 9. Location Manager(s) 10. Is Applicant an American Citizen or Alien lawfully admitted for permanent residency? ( ) Yes ( ) No OWNERSHIP INFORMATION 11. Corporation (if applicable): Date Chartered: 12. Mailing Address: Name of Business Attention Address City/State/Zip 13. Ownership Type: ( ) Corporation ( ) Partnership ( ) Individual 14. Corporate Name: List name and other required information for each person having interest in this business. Name Position SSNO # Address Interest 15. What type of business will you operate in this location? ( ) Restaurant ( ) Lounge ( ) Convenience Store ( ) Package Store ( ) Other: License Information Liquor Beer Wine Dance Sunday Sales Retail Package Dealer Consumption on Premises Wholesale Total License Fee: $ Prorated License Fee: (After July 1 ONLY) $ 16. Have you ever applied for an Alcohol Beverage License before: If so, give year of application and its disposition: 17. Are you familiar with Georgia and Augusta-Richmond County laws regarding the sale of alcoholic beverages? ( ) Yes ( ) No If so, please initial. ---PAGE BREAK--- 18. Attach a passport-size photograph (front view) taken within two years. Write name on back of the dealer submitting the license application. 19. Has any liquor business in which you hold, or have held, any financial interest, or are employed, or have been employed, ever been cited for any violation of the rules and regulations of Richmond County or the State Revenue Commission relating to the sale and distribution of distilled spirits? ( ) Yes ( ) No If yes, give full details: 20. Have you ever been arrested, or held by Federal, State, or other law-enforcement authorities, for any violation of any Federal, State, County or Municipal law, regulation or ordinance? (Do not include traffic violations, with the exception of any offenses pertaining to alcohol or drugs.) All other charges must be included, even if they are dismissed. ( ) Yes ( ) No If yes, give reason charged or held, date and place where charged and its disposition. 21. List owner or owners of building and property. 22. List the name and other required information for each person, firm or corporation having any interest in the business. 23. If a new application, attach a surveyor’s plat and state the straight line distance from the property line of school, church, library, or public recreation area to the wall of the building where alcohol beverages are sold. Church School Library Public Recreation 24. State of Georgia, Augusta-Richmond County, I, Do solemnly swear, subject to the penalties of false swearing, that the statements and answers made by me as the applicant in the forgoing alcoholic beverage application are true. Applicant Signature 25. I hereby certify that is personally known to be, that he/she signed his/her name to the foregoing application stating to me that he/she knew and understood all statements and answers made herein, and, under oath actually administered by me, has sworn that said statements and answers are true. This day of , in the year . Notary Public FOR OFFICE USE ONLY Department Recommendation Approve Deny Comments Alcohol Inspector Sheriff Fire Inspector The Board of Commissioners on the day of , in the year (Approved, Disapproved) the forgoing application. Administrator Date