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Year: License Number: APPLICATION FOR GORDON COUNTY MALT BEVERAGE, WINE, AND LIQUOR LICENSE Date: NOTE: Please answer all questions. Failure to answer any question in this application or falsely answering any question in this application will result in the rejection of the application. Type of Application: □Change of Ownership □Change of Responsible Party/Manager Type of License: □Retail □Consume On-Premises □Manufacturing □Wholesale □Hotel In-Room Service □Off-Premises Catering □Beer □Wine □Beer & Wine □Distilled Spirits Type of Business: □Sole Proprietorship □Corporation / LLC □Private Club (check one) □Non-Profit □For Profit □Partnership APPLICANT/RESPONSIBLE PARTY: (MUST be a resident of Gordon County per GA Code § 3-3-2) Full Name: Home Address: City: State: Zip: Phone: Driver’s License: OWNER: □Same as Applicant Full Name: Home Address: City: State: Zip: Phone: Driver’s License: BUSINESS: Name/DBA: Address: City: Zip: Phone: Description of Premises: (Convenience store, Restaurant, etc.) 1 ---PAGE BREAK--- Business Name: List all pertinent information for each officer, person, firm, or corporation having any interest in this application. (Provide a copy of the articles of incorporation, LLC, and/or partnership.) Name Date of Birth List the full name and address of every owner of the property and every owner of the building where this business is to be conducted. Name of Property/Building Owner Address Relation to applicant or owner 1. Has the applicant or any interested party submitted a previous application for an alcohol license in Gordon County? □Yes □No If yes, please say where & if it was approved or rejected: 2. Has the applicant or any party had a license revoked in the State of Georgia? □Yes □No If yes, explain: 3. Has the applicant or any interested party ever been charged, arrested, or held by Federal, State, or other Law Enforcement authorities for any violation of federal, state, county, or municipal law, regulations, or ordinances? (All charges including traffic must be included even if dismissed. Give reason charged or held, date, place where charged, and disposition) □Yes □No 4. Have you read and do you understand the County Alcoholic Beverage Ordinance? (copy attached with application) □Yes □No 5. Applicant certifies that they are not a surrogate for someone else. □Yes □No 2 ---PAGE BREAK--- Business Name: APPLICANT CONSENT FORM I hereby authorize the Gordon County Sheriff’s Department 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 in Georgia, and I authorize the Gordon County Sheriff’s Department to release any and all information or any criminal history record information pertaining to me which may be in the files of the City of Calhoun Police Department / Gordon County Sheriff’s Office. I also authorize release of any and/or all information which may concern my past and present status. The release of any and all information is authorized whether same is of record or not, and I do hereby release all persons, firms, agencies, companies, groups, or installations, whomsoever, from any damages because of, or resulting from furnishing such information. Information received as a result of this records check is subject to review by the Gordon County Board of Commissioners or any other licensing or hiring committee of Gordon County. This review is subject to take place in a closed or open meeting with members of the press or citizens in attendance. Applicant Name (Print): Applicant Signature: Notary Public: My Commission Expires: (Affix Seal) NOTE: Before signing this statement, check all answers and explanations to see that you have answered all questions fully and correctly. This is to be executed under oath and subject to penalties of false swearing, and it includes all attached sheets submitted herewith. APPLICANT VERIFICATION I, , do solemnly swear, subject to the penalties of false swearing, that the statements and answers made by me as the Applicant in the foregoing personal statement are true. Applicant Signature Notary Public My Commission Expires (Affix Seal) 3 ---PAGE BREAK--- Business Name: TO BE COMPLETED BY THE GORDON COUNTY SHERIFF’S OFFICE I have reviewed the above application and recommend the application be: □Approved □Not Approved GORDON COUNTY SHERIFF’S OFFICE DATE Applicant is to take this form to the Sheriff’s Office in Resaca at the Jail and Sheriff’s Office Building and bring it back to the County Clerk with the report. TO BE COMPLETED BY THE TAX COMMISSIONER’S OFFICE This is to certify that the applicant has no delinquent taxes owed to Gordon County against any real or personal property pertaining to the location where the business is to be located. In addition, there are no delinquent taxes owed to Gordon County by the applicant, owner, or party of interest in the business for which application is made. TAX COMMISSIONER’S OFFICE DATE Applicant is to take this form to the Tax Commissioner’s Office and bring it back to the County Clerk. 4 ---PAGE BREAK--- Business Name: THIS PAGE TO BE COMPLETED BY GORDON COUNTY CLERK’S OFFICE PAYMENT INFORMATION Date Fees Paid: Amount Paid: Cash Check/Money Order # Payment Received by: TO BE COMPLETED BY GORDON COUNTY CLERK Application considered by Board of Commissioners: Date Approved: Date Not Approved: Date Issued: License Number: CLERK OF BOARD 5