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(2/22) RENEWAL OF LIQUOR LICENSE OR PERMIT APPLICATION FOR LIQUOR DIVISION USE ONLY Customer Trf from: Reviewer: Initials Date Agent: / / Mgr: / / 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 Local Mailing Address: Number & Street or P.O. Box City State Zip Local Business Telephone Number: _ Fax Number: Business E-Mail FILING IN (CHOOSE ONLY ONE) FILING AS (CHOOSE ONLY ONE) CITY INDIVIDUAL CORPORATION PARTNERSHIP LTD PARTNERSHIP COUNTY LP/LLP ORGANIZATION LLC OTHER TYPE OF LICENSE OR PERMIT (CHOOSE ONLY ONE) RETAIL LIQUOR LICENSE RESTAURANT LIQUOR LICENSE MICROBREWERY PERMIT BAR AND GRILL LIQUOR LICENSE WINERY PERMIT ON-PREMISE ONLY RESORT LIQUOR LICENSE DISTILLERY SATELLITE PERMIT (BAR) WINERY SATELLITE PERMIT LIMITED RETAIL LIQUOR LICENSE (CLUB) COUNTY MALT BEVERAGE PERMIT OFF-PREMISE ONLY VETERANS CLUB SPECIAL MALT BEVERAGE PERMIT (PACKAGE STORE) FRATERNAL CLUB GOLF CLUB SOCIAL CLUB COMBINATION ON/OFF PREMISE (BOTH BAR & PACKAGE STORE) SPECIAL DESIGNATIONS (CHOOSE ONLY ONE) GOLF CLUB GUEST RANCH RESORT To Assist the Liquor Division with scheduling inspections: OPERATIONAL STATUS (specify months of operation) FULL TIME (e.g. Jan through Dec) from to DAYS OF WEEK (e.g. Mon through Sat) SEASONAL/PART-TIME from to HOURS OF OPERATION (e.g. 10a - 2a) NON-OPERATIONAL/PARKED from to 1. BUILDING OWNERSHIP: Does the applicant? W.S. 12-4-103(a)(iii) OWN the licensed building? YES (own) LEASE the licensed building? (Lease must be through the term of the liquor license) YES (lease) LEASE is current and on file with the licensing authority & Liquor Division. If the lease is not current, please submit a copy pf the lease and indicate: When the lease expires, located on lease. (ii) Where the Sales provision for alcoholic or malt beverages is located, on paragraph____________of lease. (MUST contain a provision for SALE OF ALCOHOLIC or MALT BEVERAGES.) ---PAGE BREAK--- (2/22) 2. BAR AND GRILL LICENSE OR RESTAURANT LICENSE HOLDERS ONLY: Gross sales figures and percentages of income derived from: (Line 1) Liquor Sales: W.S.12-4-408(b) (Line 2) Food Sales: (Line 1 + Line 2 must = Line 3) (Line 3) Gross Sales: Have you submitted a valid food service permit or application? W.S. 12-4-413(a) YES NO 3. MICROBREWERY LICENSE HOLDERS ONLY: Did you produce over 50 barrels (1,550 gallons) but less than 50,000 barrels (1,550,000 gallons) during the previous license term? W.S.12-1-101(a)(xix) YES NO Do you self distribute your products? W.S. 12-2-201(a) YES NO (Requires wholesale malt beverage license with the Liquor Division) 4. SOCIAL CLUB LICENSE HOLDERS ONLY: Have you files a detailed statement of your activities during the year with an itemized statement of amounts expended? YES NO 5. If applicant is filing as an Individual, Partnership or Club: W.S. 12-4-102(a)(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 (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(a)(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 (If more information is required, list on a separate piece of paper and attach to this application) 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 Witness my hand and official seal: Signature of Notary Public (SEAL) My commission