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2023 APPLICATION FOR GORDON COUNTY MALT BEVERAGE, WINE AND LIQUOR LICENSE 1. Business is: Sole Proprietorship Corporation Private Club (check one) ___Non-Profit ___For Profit Partnership 1 a. Name of owner(s) Sole of Corporation (list of officers) Partnership (list partners) Private Club (list officers) 1. b. Name of applicant Date of 2. Name of corporation (if a 3. 4. How long a resident of Gordon 5. Name of Phone Type of application: wine, alcohol, consumption) 6. Location of 7. Description of premises (convenience store, 8. Has the applicant or any interested person made a previous application for a license in Gordon County ( ) Yes ( ) No If yes: approved or 9. Has applicant or any person with any interest in the application ever been convicted of a crime other than traffic violation ( )Yes ( )No If yes: What 10. Name and address of all persons (other than applicant) who have a direct or indirect interest in the profits or losses of the Submitted this day of Print Applicant’s Signature of Applicant Sworn to and subscribed before me this day of Notary Public My Commission (Notary Seal) Applicant: Fill out and bring to the County Clerk Office File: MaltBevApp-LIC20223 ---PAGE BREAK--- NOTICE TO PUBLIC applied to Gordon County for a Beer, Wine, Liquor, or Consumption on the Premises (strike all that do not apply) License. This application was submitted on behalf of The place of business of the Applicant is The application will be considered by the Board of Commissioners at its Regular Meeting in the Judicial Building, 101 S. Piedmont Street on The day of 2022, at o’clock a.m./p.m.. Signature of Applicant Applicant: This Form must be presented to the County Clerk first and then take this form to the Newspaper Office ---PAGE BREAK--- CONSENT FORM FOR CRIMINAL HISTORY I HEREBY AUTHORIZE GORDON COUNTY TO RECEIVE ANY CRIMINAL HISTORY RECORD INFORMATION PERTAINING TO ME WHICH MAY BE IN THE FILES OF ANY FEDERAL, STATE, OR LOCAL CRIMINAL JUSTICE AGENCY. THE FEE FOR THIS SERVICE IS INCLUDED IN THE LICENSE APPLICATION FEE FOR MALT BEVERAGE/WINE/ALCOHOL COLLECTED BY THE GORDON COUNTY ADMINISTRATION DEPARTMENT. FULL NAME STREET CITY/STATE/ZIP SEX RACE DATE OF BIRTH SOCIAL SECURITY NUMBER Sworn to and subscribed before me this day of Notary Public My Commission Expires Applicant: Take this form to the Sheriff’s Office in Resaca at the Jail and Sheriff’s Office Building bring back to the County Clerk’s office with the report ---PAGE BREAK--- TAX CERTIFICATION Notice is hereby given that has no (Name of applicant) delinquent taxes owed to Gordon County against any real or personal property pertaining to the following location where the proposed business is to be In addition, there are no delinquent taxes owed to Gordon County by (applicant, owner, or party of interest in the business for which application is made) (Gordon County Tax Commissioner’s Office) Applicant: Take this form to the Tax Commissioner’s Office and bring back to the County Clerk ---PAGE BREAK---