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Form # 2-A Revised 1-1-12 Page 1 of 1 DAWSON COUNTY PLANNING AND DEVELOPMENT Alcohol Licensing 25 Justice Way, Suite 2322 Dawsonville, GA 30534 (706) 344-3500 x 42335 * REGISTERED AGENT CONSENT FORM Business Name Business Address I, , do hereby consent to serve as the Registered Agent for the licensee, owners, officers, and/or directors and to perform all obligations of such agency under the Alcoholic Beverage Ordinance of Dawson County. I understand the basic purpose is to have and continuously maintain a Registered Agent upon which any process, notice, or demand required or permitted by law or under said Ordinance to be served upon the licensee or owner may be served. This day of , 20 . Signature of Agent Print Name of Agent Print Agent's Street Address Print Agent's City - County - State - Zip Code Agent's Phone Number APPROVED: Sole Owner / Partner Officer or Director Title *Note: Naming a Registered Agent is optional under the Consolidated Alcohol Ordinance of Dawson County.