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WLD-31 (4/17) NEW OR TRANSFER LIQUOR LICENSE OR PERMIT APPLICATION FOR LIQUOR DIVISION USE ONLY Customer Trf from: Reviewer: Initials Date Agent: / / Chief: / / To be completed by City/County Clerk Local License License Fees Annual Fee: Date filed with clerk: Prorated Fee: Advertising Dates: (2 Weeks) Transfer Fee: Publishing Fee: Hearing Date: Publishing Fee Direct Billed to Applicant: License Term: / Through / Month Day Year Month Day Year LICENSING AUTHORITY: Begin publishing As W.S. 12-4-104(d) specifies: NO LICENSING AUTHORITY SHALL APPROVE OR DENY THE APPLICATION UNTIL THE LIQUOR DIVISION HAS CERTIFIED THE APPLICATION IS COMPLETE. Applicant: Trade/Business Name (dba): Building to be licensed/Building Address: Number & Street City State Zip County Mailing Address: Number & Street or P.O. Box City State Zip Business Telephone Number: _ Fax Number: E-Mail Brief legal description and the zoning of the licensed building or site for licensed building: W.S. 12-4-102 (vi) FILING FOR FILING IN (CHOOSE ONLY ONE) FILING AS (CHOOSE ONLY ONE) NEW LICENSE CITY INDIVIDUAL PARTNERSHIP TRANSFER OF LOCATION COUNTY LP/LLP LLC CORPORATION TRANSFER OWNERSHIP ASSIGNMENT LETTER ATTACHED LTD PARTNERSHIP ORGANIZATION FORMERLY HELD OTHER TYPE OF LICENSE OR PERMIT (CHOOSE ONLY ONE) RETAIL LIQUOR LICENSE RESTAURANT LIQUOR LICENSE MICROBREWERY ON-PREMISE ONLY RESORT LIQUOR LICENSE WINERY (BAR) BAR AND GRILL DISTILLERY SATELLITE WINERY SATELLITE OFF-PREMISE ONLY LIMITED RETAIL (CLUB) COUNTY RETAIL or SPECIAL (PACKAGE STORE) VETERANS CLUB MALT BEVERAGE PERMIT FRATERNAL CLUB SPECIAL DESIGNATIONS COMBINATION ON/OFF PREMISE GOLF CLUB CONVENTION FACILITY (BOTH BAR & PACKAGE STORE) SOCIAL CLUB CIVIC CENTER/EVENT CENTER/ PUBLIC AUDITORIUM GOLF CLUB GUEST RANCH RESORT To Assist the Liquor Division with scheduling inspections: WHEN DO YOU OPERATE? FULL TIME (e.g. Jan through Dec) SEASONAL/PART-TIME NON-OPERATIONAL/PARKED (specify months of operation) DAYS OF WEEK (e.g. Mon through Sat) HOURS OF OPERATION (e.g. 10a - 2a) from to from to from to ALL APPLICANTS MUST COMPLETE QUESTIONS 1- 6 1. BUILDING OWNERSHIP: Does the applicant? W.S. 12-4-103 (iii) OWN the licensed building? YES (own) LEASE the licensed building? (Lease must be through the term of the liquor license) YES (lease) If Yes, please submit a copy of the lease and indicate: When the lease expires, located on page_____paragraph_____of lease. Where the Sales provision for alcoholic or malt beverages is located, on page_____paragraph_____of lease. (MUST contain a provision for SALE OF ALCOHOLIC or MALT BEVERAGES.) ---PAGE BREAK--- WLD-31 (4/17) 2. To operate your liquor business, have you assigned, leased, transferred or contracted with any other person (entity) to operate and assert total or partial control of the license and the licensed building? W.S. 12-4-601 YES NO 3. Does any manufacturer, brewer, rectifier, wholesaler, or through a subsidiary affiliate, officer, director or member of any such firm: W.S. 12-5-401, 12-5-402, 12-5-403 Hold any interest in the license applied for? YES NO Furnish by way of loan or any other money or financial assistance for purposes hereof in your business? YES NO Furnish, give, rent or loan any equipment, fixtures, interior decorations or signs other than standard brewery or manufacturer's signs? YES NO If you answered YES to any of the above, explain fully and submit any documents in connection there within: 4. Does the applicant have any interest or intent to acquire an interest in any other liquor license issued by this licensing authority? W.S. 12-4-103 YES NO If "YES", explain: 5. If applicant is filing as an Individual, Partnership or Club: W.S. 12-4-102 (ii) & (iii) Each individual, partner or club officer must complete the box below. True and Correct Name Date of Birth Residence Address No. & Street City, State & Zip DO NOT LIST PO BOXES Residence Phone Number Have you been a DOMICILED resident for at least 1 year and not claimed residence in any other state in the last year? Have you been Convicted of a Felony Violation? Have you been Convicted of a Violation Relating to Alcoholic Liquor or Malt Beverages? YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO (If more information is required, list on a separate piece of paper and attach to this application.) 6. If the applicant is a Corporation, Limited Liability Company, Limited Liability Partnership or Limited Partnership: W.S. 12-4-102 (iv) & Each stockholder holding, either jointly or severally, ten percent (10%) or more of the outstanding and issued capital stock of the corporation, limited liability company, limited liability partnership, or limited partnership, and every officer, and every director must complete the box below. True and Correct Name Date of Birth Residence Address No. & Street City, State & Zip DO NOT LIST PO BOXES Residence Phone Number No. of Years in Corp or LLC % of Corporate Stock Held Have you been Convicted of a Felony Violation? Have you been Convicted of a Violation Relating to Alcoholic Liquor or Malt Beverages? YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO (If more information is required, list on a separate piece of paper and attach to this application) ---PAGE BREAK--- WLD-31 (4/17) 7. BAR AND GRILL LICENSE: Have you submitted a valid food service permit or application? W.S. 12-4-413 YES NO 8. RESTAURANT LICENSE: Give a description of the dispensing room(s) and state where it is located in the building. W.S. 12-4-408 (e.g. 10 x 12 room in SE corner of Have you submitted a valid food service permit or application? W.S. 12-4-407 YES NO Have you attached a drawing of the establishment that includes the restaurant dispensing room(s)? W.S. 12-4-410 YES NO 9. RESORT LICENSE: Does the resort complex: Have an actual valuation of at least one million dollars, or have you committed or expended at least one million dollars ($1,000,000.00) on the complex, excluding the value of the land? W.S. 12-4-401(b)(i) YES NO Include a restaurant and a convention facility which will seat at least one hundred (100) persons? W.S. 12-4-401(b)(ii) YES NO Include motel, hotel or privately owned condominium, town house or home accommodations approved for short term occupancy with at least one hundred (100) sleeping rooms? W.S. 12-4-401(b)(iii) YES NO If no on question have a ski resort facility open to the general public in which you have committed or expended not less than 10 million dollars ($10,000,000.00)? W.S. 12-4-401(b)(iv) YES NO Are you contracting/leasing the food and beverage services? W.S. 12-4-403(b) 1. If Yes, have you submitted a copy of the food and beverage contract/lease? YES NO 10. MICROBREWERY LICENSE: Will the license be held in conjunction with another liquor license? W.S. 12-4-412(b)(iii) YES NO If "YES", please specify type: RETAIL RESTAURANT RESORT BAR AND GRILL WINERY Do you self distribute your products? W.S. 12-2-201(a) YES NO (Requires wholesaler license with the Liquor Division) Do you distribute your products through an existing malt beverage wholesaler? W.S. 12-2-201(g)(i) (Requires authorization to sell license with the Liquor Division) YES NO 11. WINERY LICENSE: Will the license be held in conjunction with another liquor license? W.S. 12-4-412(b)(iii) YES NO If "YES", please specify type: RETAIL RESTAURANT RESORT BAR AND GRILL MICROBREWERY 12. LIMITED RETAIL (CLUB) LICENSE: FRATERNAL CLUBS W.S. 12-1-101(a)(iii)(B) Has the fraternal organization been actively operating in at least thirty-six (36) states? YES NO Has the fraternal organization been actively in existence for at least twenty (20) years? YES NO 13. LIMITED RETAIL (CLUB) LICENSE: VETERANS CLUBS W.S. 12-1-101(a)(iii)(A): Does the Veteran’s organization hold a charter by the Congress of the United States? YES NO Is the membership of the Veteran's organization comprised only of Veterans and its duly organized auxiliary? YES NO 14. LIMITED RETAIL (CLUB) LICENSE: GOLF CLUBS W.S. 12-1-101(a)(iii)(D)/W.S. 12-4-301(e): Do you have more than fifty (50) bona fide members? YES NO Do you own, maintain, or operate a bona fide golf course together with clubhouse? YES NO Are you a political subdivision of the state that owns, maintains, or operates a golf course? YES NO 1. Are you contracting/leasing the food and beverage services? W.S. 12-5-201(g) YES NO 2. If Yes, have you submitted a copy of the food and beverage contract/lease? YES NO ---PAGE BREAK--- WLD-31 (4/17) 15. LIMITED RETAIL (CLUB) LICENSE: SOCIAL CLUBS W.S. 12-1-101(a)(iii)(E)/W.S. 12-4-301(b): Do you have more than one hundred (100) bona fide members who are residents of the county in which the club is located? YES NO Is the club incorporated and operating solely as a nonprofit organization under the laws of this state? YES NO Is the club qualified as a tax exempt organization under the Internal Revenue Service? YES NO Has the club been in continuous operation for a period of not less than one year? YES NO Has the club received twenty-five dollars ($25.00) from each bona fide member as recorded by the secretary of the club and are club members at the time of this application in good standing by having paid at least one full year in dues? YES NO Does the club hold quarterly meetings and have an actively engaged membership carrying out the objectives of the club? YES NO Have you filed a true copy of your bylaws with this application? YES NO Has at least fifty one percent (51%) of the membership signed a petition indicating a desire to secure a Limited Retail Liquor License? (Petition Attached) YES NO REQUIRED ATTACHMENTS: A statement indicating the financial condition and financial stability of the applicant W.S. 12-4-102 (vi). Restaurants: include a drawing of the establishment that includes the dispensing room(s) W.S. 12-4-410 Attach any lease agreements (especially for resort/political subdivisions leasing out food & beverage services) W.S. 12-4-103 (iii)/ W.S. 12-4-403(b)/W.S. 12-4-301(e). If transferring a license from one ownership to another, a form of assignment from the current licensee to the new applicant authorizing the transfer W.S. 12-4-601 OATH OR VERIFICATION (Requires signatures by ALL Individuals, ALL Partners, ONE LLC Member, or TWO Corporate Officers or Directors except that if all the stock of the corporation is owned by ONE individual then that individual may sign and verify the application upon his oath, or TWO Club Officers.) W.S. 12-4-102(b) Under penalty of perjury, and the possible revocation or cancellation of the license, I swear the above stated facts, are true and accurate. STATE OF WYOMING ) ) SS. COUNTY OF ) Signed and sworn to before me on this day of that the facts alleged in the foregoing instrument are true by the following: 1) (Signature) (Printed Name) Title 2) (Signature) (Printed Name) Title 3) (Signature) (Printed Name) Title 4) (Signature) (Printed Name) Title 5) (Signature) (Printed Name) Title 6) (Signature) (Printed Name) Title Witness my hand and official seal: Signature of Notary Public (SEAL) My commission