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CITY OF JEROME ALCOHOLIC BEVERAGE APPLICATION Application is hereby made this day of , 20 to the City of Jerome for the following license(s): This Application is for: o Original license Transfer of License In support of this Application, I certify under oath the following to be true and correct: Business Name Business Mailing Address Business location Name of Applicant Length of Residence in Idaho Contact telephone number (Complete floor plan sketch on attached Exhibit A) Is business a partnership? If yes, provide names, addresses and residence length of all partners: Partner name Address Residence length Is business a corporation? If yes, fill out corporation questionnaire attached. The requisite fee of $ , made payable to the City of Jerome, is attached to this application. APPLICATION – 1 Beer, consumption on premises ($100.00) Transfer Fee $25.00 Beer, consumption off premises 25.00) Transfer Fee $25.00 Wine, consumption on premises ($200.00) Transfer Fee $25.00 Wine, consumption off premises ($100.00) Transfer Fee $25.00 Liquor, consumption on premises ($562.50) Transfer Fee $50.00 ---PAGE BREAK--- Name of business manager and residence length, if different than applicant: Name Residence length I have completed and attached Exhibit B to this application, entitled "Personal Disclosure Statement." THE UNDERSIGNED MAKES THESE STATEMENTS WITH THE KNOWLEDGE THAT ANY KNOWING MISREPRESENTATION MAY BE GROUNDS FOR TERMINATION OF A LICENSE GRANTED, OR REFUSAL OF THE LICENSE APPLIED FOR. STATE OF IDAHO (signature) State of Idaho ) SS. County of Jerome ) On this day of 2 , before me, the undersigned, a Notary Public in and for said County and State, personally appeared , known to me to be the person whose name is subscribed to the within and foregoing instrument, and who acknowledged to me that he executed the same. IN WITNESS WHEREOF, I have hereunto set my hand and seal, the day and year in this certificate first above written. NOTARY PUBLIC FOR STATE OF RESIDING AT APPLICATION - 2 SIGN ---PAGE BREAK--- EXHIBIT A TO LICENSE APPLICATIONS - BEER, WINE, LIQUOR. Provide a sketch of the premises for which license is sought. Show entire area to be licensed; adjacent streets, if any; entrances and exits; location of licenses to be displayed; bar, if any; liquor, wine or beer storage area, if any; booths and tables, if any; show the direction and distance to the nearest school, church or other places of worship, measuring from the nearest entrance of the licensed premises to any school, church or other places of worship if within 300 feet. Drawing may be attached. I certify that the building of which the above premise is a part conforms to all requirements of State law and regulation, as well as County and Municipal Ordinances, related to public health, safety and zoning. Applicant ---PAGE BREAK--- APPLICATION – Exhibit A CORPORATION QUESTIONNAIRE, CITY LIQUOR, WINE OR BEER LICENSE APPLICATIONS Name of Corporation DBA, if any Street address Officers & Directors (May attach a separate sheet if necessary) TITLE NAME ADDRESS (RESIDENTIAL) ATTORNEY Name Address Date of incorporation Place of incorporation Corporation principal office: Corporation's registered Idaho agent: DATED this day of , 2 . (Signature) Title: SIGN ---PAGE BREAK--- Corporation Questionnaire – Page 1 STATE OF ) ) Ss. County of ) On this day of , 2 , before me, the undersigned, a Notary Public in and for said County and State, personally appeared known to me to be a duly qualified officer of , an Corporation, whose name is subscribed to the within and foregoing instrument, and who acknowledged to me that he executed the same. IN WITNESS WHEREOF, I have hereunto set my hand and seal, the day and year in this certificate first above written. NOTARY PUBLIC for Residing at: ---PAGE BREAK--- Corporation Questionnaire – Page 2 EXHIBIT B TO APPLICATIONS FOR LIQUOR, WINE OR BEER LICENSES (On premise consumption applicants only) "PERSONAL DISCLOSURE STATEMENT" Name of applicant Business name and address Do you own or rent business premises? If you rent, attach copy of lease to this exhibit. Home address Home telephone Place of birth If U.S. Citizen by naturalization, Date of naturalization Interest in business (check one or more) Sole owner Officer Shareholder Manager Partner Do you have a direct or indirect interest in any other business licensed for the sale of alcoholic beverages? If yes, explain: Have you ever been a licensee of an alcoholic beverage, partner, director, or officer of a licensee or applicant, whose license has been denied, suspended or revoked? If yes, explain: Present and past employment (2 years back) Employer Name City State Job Description Dates ---PAGE BREAK--- Exhibit B - 1 Have you ever been arrested, convicted, fined, jailed or placed on probation for violation of any law? If yes, explain fully Date of arrest Place of arrest Offense Result Do you use any alias? If yes, list all aliases: HEIGHT WEIGHT HAIR EYES I have read the foregoing and upon penalty of perjury, declare each statement by me to be true and correct. I understand an investigation to corroborate these statements will be made. DATE: APPLICANT Exhibit B - 2