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Liquor License Officer Update Form Page 1 of 1 CITY OF DOUGLAS LIQUOR LICENSING Change in Licensee Information This form must be completed and provided to the City of Douglas within thirty (30) days of any change(s) within a corporation, LLC, LLP, or club holding a liquor license for each of the following: all stockholders holding 10% or more of stock, all partners, all officers, and all directors. This information is required and authorized per W.S. §12-4-102 and Douglas Municipal Code, Title 5.16. LICENSEE INFORMATION 1. Applicant Name (Name the liquor license is held in): 2. Trade Name (DBA) 3. Premise Address: 4. Primary Phone 5. Type of License Held: 6. List the following for ALL officers of the entity: Legal name, birthdate, phone number, and amount of stock held. Each officer must also answer the violation questions. True and Correct Name Date of Birth DONOT LIST PO BOXES Residence Address No. & Street City, State & Zip Residence Phone Number No. of Years in Corp or LLC % of 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 additional space is needed, please attach an additional page(s). I hereby certify the above information to be true and correct to the best of my knowledge. SIGNATURE of APPLICANT DATE PRINTED NAME EFFECTIVE DATE OF CHANGE SIGN