APPLICATION FOR RETAIL ALCOHOLIC BEVERAGE LICENSE. Applicants should complete the application in full. Where a question is not applicable, please
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lRS:FEEOATESTATE OF NEW JERSEYDEPARTMENT OF LAW AND PUBLIC SAFETYDIVISION OF ALCOHOLIC BEVERAGE CONTROLAction 1D CodeliltllAWDUSTATE ASSIGNED LICENSE NUI\,IBERlFor DIVISION use only _ lDATE APPLICATION FILEDTHIS APPLICATION IS FORcooE rYPE oF LtcENSE (CHECK ONE)CLASS C LICENSES [R.S.33:1-12]31 _ Club32 Ple.rarv Retarl Consumotronw/Bioad Package Privrtege33 _ Plenary Retail Consumplion36 Plenarv Retail Consumohon(Hofet/t otel Excephon)37 Plenarv Retail Consumolion(Thdatre Exception)35 Seasona, Relall ConsumDtton(November 15 througli April 30)Seasonal Relarl Consumotron(May 1 lhrough Novefliber 14)_ Plenary Retail DrstribulionLimited Retail DistributionA New LicensePerson-to-Person Transfer{lncludino PartnershrD chanoeaxcept Lr-mrted Panniirship.)”Place-to-Place Transfer(lncluding expansion of premises)Change of Corporate StructureE{tension of License (to Execulor,Receiver, Administralor, elc.)Renewal of LicenseAmendment ol Application on FileOther344443OTHER1440Annual State Permit(R.S. 33;1-42, NJAC 1 3;2-52)_ Speqiil ?erqril lor a Golf Facility(NJAC 13:2-5.3)Municlpal Fee $Effective Date _l(As Stated in ResolulionDale Denied I(As Stated in Resolution)Refund Amouni $Special Condilions AttachedThis Area is Reserved for Municipal UseDate of resolulion unless olherwise established.)State Fee SYesSignature of Municipal Clerk or ABC SecrelaryBC SecrelaryType or Prini Name (Last Name, First Name, Middle lnitial) ol Municipal Clerk or ARETAIL LIOUOR LICENSE APPLICATIONttNo
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-aa= aPLaAS= f ‘,P; OR Pi.tr’tT ALL ti.JaO:,i\rl-itOr’i:T,!TE ASSIGI!ED LI:=ri S: I,JLIhriS=RADplicaiion is m3d: on b:h3li oi1 = An lndividuel3 = A Partnechip5 = lncorporated Club2=Business CorporeiionUnincoDorated CIubLimited Partnership7 = Lirniied Liabiliry Companyl’lAl\4E(S) AS lT DOES OR \ /lLL.\PPEAR Ol.,lTHE LICENSE CERIIFICATE (l,lOT “TRADE’ NAlrriQ:License m=y be h.]d by Lndividual (Lasi l.Jame, Flrst Name lviiddle lniiian, panneiship or Corporaijon2.2fLest Name, Fi.si Name, xiiddle lniti3l or Copcr3i: lifme)ACTUAL ADDP,ESS VVHER.E THE LICEIISE IS TO BE USED (SITED PREIUISES):Stieet AddressNumber Str-eet l\amelvlunicipatrty Zip _-Telephone Number of Business ( _ )E-l\,lail AddressA[Ea Exchange l\iumberlino licensed premises exisis or ifa mailing address is different than the “actual addESS” given above, pr-ovide ttre mailing addles(insert N/A if not applicable):Street AddressIrlum b erStreet l\ameP.C. 3ox #f.lunicipalil,zipTelep\one (_ )_ – _2.4 New Jersey Sales Tax Certificate oiAlthority l\loTRADE NAME(S) UNDER VYHICH BUSINESS lS TO BE CoNDUCTED. ALL TRADE NAI\,4ES [4UST BE LISTED Al\]DREGISTERED Wml THE l!.J. SECRETARY OF STATE Iif a corporationl OR COUNTY CLERK Iif a parlnership or soleprDprietorl:THE FOLLOWING QUESTIONS ARE TO 3E ANSWERED EY ALL APPL)CANTS OTHER THAN APPLICANTS FOR A NEWLICENSE:A, IS THE LICENSE ACTIVELY USED ATAN OPERATING PLACE OF BUSINESS?Yes NoIF NO, GIVE THE DATE THE BUSINESS STOPPED OPERATING (OR THE DATE THE LICENSE WAS ORIGINALLYISSUED IF NEVER SITED ATAN OPERATING BUS]NESS):llC, IF THE LICENSE IS INACTIVE AND THE APPLICAT]ON IS FOR A TRANSFER, V\IILL IFiE LICENSE BE USED AT ANOPERAING PLACE OF BUSINESS AFTER APPROVAL?Yes No2.7 THE FOLLOTJING QUESTIONS ARE TO BE ANSWERED BY AN APPL]CANT FOR A NEW LICENS=A. W LL THE LICENSE BE USED AT AN OPER-ATING PLACE oF BUSINESS II\4II.4EDIATELY UPON ISSUANCE?Yes NoB. LF NO, PROVIDE ANT]CLPATED DATE OF LICENSE ACTIVAIION1t2.5
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Page 3PLEASE ryPE OR PRINT ALL INFORMATIONSTATE ASSIGNED LICENSE NUMBERThe iollowing questions identity information about the licensed premises. This describes the area or place which ls lo be licensed for lhesale, service, consumption. delivery, receipt or storage of alcoholic beverages. lf the license is inactive and NOT SITED AT A PLACE OFBUSINESS, answer queslion 3 1 only, entenng N/A for “not applicable.” lfyou use N/A as a response lo question 3.1, question 2.2 onPage 2 should also be answered N/A l3,1 HOW IUANY SEPARATE BUILDINGS ARE TO BE INCLUDED UNDER THIS LICENSE?It more lhan one building is to be included under this license, a separate Page 3 is to be submitled covering each buildingAn uplo-date sketch ol the enlire licensed premises should be submitted for inclusion in the Slaie ABC license file.3.2 BUILDING NOor:TO BE LICENSED3.3 lS THE ENTIRE BUILDING TO BE LICENSED? Yes _ Noil the answer to question 3.3 is “No, specify which floors are to be under license and which ones are nol by answeringtollowing questionsl34 Easement _Yes _No All orit _Yes _No1’rfloor -Yes _No Att orit _Yes No2no f’oor -Yes _No All of it _Yes _No3’u floor – Yes _ No All of it _ Yes _ NoSpecify each addilional floor number to be included under lhis license;It only part of any floor is to be licensed, attach a more detailed explanation with sketches to clearly delineate licensed areasfrom unlicensed areas.3,5 ARE ANY GROUNDS ADJACENT TO THE BUILDIN6 UNDER LICENSE TO BE INCLUDED AS PART OF THE LICENSEDPREMISES?_Yes -_No36 IS IHERE ANY UNLICENSEDAREA LOCATED BETWEEN BUILDINGS UNOERTHIS LICENSE OR BETWEEN LICENSEDADJACENT GROUNDS?-Yes -NoIF THE ANSWER IS “YES,” ATTACH A SKETCH OF TI.IE LICEN$ED AND UNLICENSED AREAS SHOWING DIMENSIONSIN FEET37 DOES THE APPLICANT OWN THE BUILDING? -Yes -NolF “YES,” lS THERE A MORTGAGE ON rHE BUILDING? -Yes – NoDOES rHE APPIICANT LEASE THE BUILDING? -Yes -Nolf there is a morlgage on the prope(y, answer queslion 3 L lf lhe licensed premise is leased, answer queslion 3.9.3.8 MORTGAGEE (HOLDER OF MORTGAGE)the(Last Name, First Name, [.4iddle lnitial or Corporate Name)Slreel AddressNumberStreet Namezip — -3 9 LANDLORD (HOLDER OF LEASE)N/lLrnicipality(Last Name, First Name, Middle lnilial or Corpo.ate Name)Slreet AddressNumberP O. Box # _ i,lunicipalityzip—-Street NameSlateP.O. Box #State –*-
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Page 4PLEASE IYPE OR PRINT AtL INFORMATIONSTAIE ASSIGNED LTCENSE NUII,BER414.24.3444.5IS THE NEAREST ENTRANCE OF THE PLACE TO BE TICENSEO WITHIN 2OO FETT OF THE NEARESTENTRANCE OF ANY CHURCH OR SCHOOL? _ Yes _ NoTHE ANSWER IS “YES,” IS A WAIVER SIGNED BY THE APPROPRIATE OFFICIAL ATTACHED TO THISAPPLICATION? – YES -NODOES THT APPLICANT INTEND TO USE ANY VEHICLES FOR THE TRANSPORT OR DELIVERY OFALCOHOLIC BEVERAGES? _ Yes _ No (A TRANSIT INSIGNIA lS NECESSARY BEFOREALCOHOLiC BEVERAGES MAY BE TRANSPORTED,)HAS THE APPLICANT FILED AN ANNUAL SPECIAL TAX REGISTRATION AND RETURN FORM (TTB F5630.5) WITH THE FEDERAL ALCOHOL ANO TOBACCO TAX AND TRADE BUREAU?_Yes _NoIF ‘YES’DATE FILED I IWILL ANY BUSINESS OTHER THAN THE SAIE OF ALCOHOLIC BEVERAGES BE CONDUCTED ON THEPREMISES TO BE LICENSED? _ Yes _ NoIF THE ANSWER IS ‘YES,’ INDICATE THE NATURE OF THE BUSINESS AND WHO WILLCONDUCT IT BYRESPONDING TO THE FOLLOWING QUESTIONSi_ Restaurant _ Applicant – Other_ Catenng – Applicant – Other_ Hotel/Motel – Applicant – otherAmusements -Applicant -Other- N.J. Lottery – Applicant – Other- Grocery or Delicatessen – Applicant – Other- Other (specify) – Applicant – OtherIF SOMEONE OTHER THAN THE APPLICANTWILL OPERATE THE OTHER BUSINESS ON THE LICENSEDPREMISES ANSWER THIS OUESTION, IF THERE IS MORE THAN ONE INDIVIDUAL OR COMPANY,ATTACH A SEPARATE PAGE LISTING THE REOUESTED INFORMATION FOR EACH OPERATORBusiness to be operatedName of company/rndrvidual(Last Name, First Name or Corporate Name)Street AddressNumberStreet NameMunicipahtyzipNJ Sales Tax Cerlificate of Authorlly No.state –
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Page 5PLEASE TYPE OR PRINT ALL INFORMAIIONALL APPLICANTS ANSWER THE FOLLOWING5 1 IS THE APPLICANT OR ANY OTHER PERSON MENTIONED IN THIS APPLICATION A POLICE OFFICEROR HOID ANY POSITION ENTRUSTED WITH THE ENFORCEMENT OF ANY LAWS CONCERNINGALCOHOTIC BEVERAGES IN ANY MANNER WHATSOEVER?_Yes _Nolf the answer is “Yes,” complete the fotlowing:Name of individualLast NameFirst Namelvliddle lnltialTitie of position heldName of Ec]o oy ^g Agelcy _52DOES THE APPLICANT OR ANY OTHER PERSON MENTIONED IN THIS APPLICATION, OR ANYPERSON HAVING A BENEFICIAL INTEREST IN THE TICENSED BUSiNESS, HOLD OFFICE IN THE UNITOF GOVERNMENT ISSUING THE LICENSE? Yes NoIF THE ANSWER IS ‘YES,, COI\iIPLETE THE FOLLOWINGName of lndividualLast NameFirst Namel\iliddle ln tialTitle of OfficeN,4unicipality5.3 DOES THE APPLICANT OR ANY OTHER PERSON IVIENTIONED IN THIS LICENSE APPLICATION, ORANYONE WITH A BENEFICIAL INTEREST IN THE LICENSED EUSINESS, DIRECTLY OR INDIRECTLY,HAVE ANY INTEREST IN ANY BREWERY, WINERY, DISTILLERY, RECTIFYING AND BLENDING PLANT,IMPORTER OR WHOLESALE ALCOHOLIC BEVERAGE BUSINESS, AS OWNER, PART OWNER,LANDLORD. TENANT, MORTGAGE HOLDER OR AS A STOCKHOLDER, OFFICER, DIRECTOR, AGENT,EMPLOYEE OR OTHERWISE?YesIF THE ANSWER IS’YES,’ATTACH AN AFFIDAVIT EXPLAINING THE RELATIONSHIP AND NATURE OFTHE INTEREST AND COMPLETE THE FOLLOWING:A. New Jersey license number, if applicableIF THE BUSINESS DOES NOT HOLD A NEW JERSEY LIQUOR LICENSE, ANSWER THE FOLLOWINGQUESTIONS:BName of entrty conducting business (Corporation, Partnership or lndividual)(Last Name. First Name, Middle lnitial or corporateNanTe)Street AddressPO Box#zipType of BusinessNumberN4unicipalityStreet NameStateSTATE ASSIGNED LICENSE NUIIBERNo
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PAgE 6 PLEASE TYPE OR PRINT ALL INFORMATIONSTATE ASSIGNED LICENSE NUI\,1BER61ALL APPLICANTS ANSWER IHE FOLLOWINGHAS THE APPLICANT EVER EEEN DENIED A LIOUOR LICENSE IN NEW JERSEY?IF THE ANSWER TO THIS QUESTION IS “YES,’ANSWER THE FOLOWING,Type of License or Pe.mlt Denied: _ Retail _ Wholesale_ Warehouse _ ManufaclurerUnit of Governmenl !ryhich denied License or permit.YesNo_ TransportationDate of Denial (approximale if nol known) _ / _ I _Reason for Denial62HAS ANY CORPORATION, PARTNERSHIP OR INOIVIDUAL I\IENTIONED IN THIS APPLICATION, OTHER THAN THEAPPLICANT. BEEN DENIED A LIOUOR LICENSE oR PERM ? Yes NoIF THE ANSWER IS.YES,” ANSWER THE FOLLOWINGNanre of Ent tyLasl NameFirst NameMiddle lnitialType of License or Permit Denied: Relail- warehouseUnil of Governmenl which denied License or permit:Date of Denial (approximate if not known) _ I _t _Reason for Denial_ Wholesale_ l\,4anu{acturer_ Transportation63HAS THE APPLICANT OR ANY OTHER PERSON, CORPORATION OR ENTIry MENTIONED IN THIS LICENSEAPPLICATION. OR ANYONE WITH A BENEFICIAL INTEREST IN IT, HAO AN INTEREST IN A NEW JERSEYALCOHOLIC BEVERAGE LICENSE WHICH WAS SURRENDERED, SUSPENDED OR HAD A PENALW IMPOSED INLIEU OF SUSPENSION NOTRENEWED, REVOKEDOR CANCELLED WITHIN THE lOYEARS PRIORTOTHEOATEOF THIS APPLICATION? _ Yes _ NolF THE ANSWER lS ‘YES.’ PROVIDE DETAILS OF EACH BELOW lcomplete a separale Page 6 for each action]:Name of lndividualLast NameOATE OF ACTION IFirsl NameDOCKET NOPENALTY WAS IN’POSED BYPENALTY CONSISTED OF,FINED $Middle lnitiaillndicate whether by Divlsion of ABC or idetrlify Local lssuing AuthoritylNOT RENEWEDREVOKEDCANCELLEDlamounllSUSPENDED(number of days)OTHER [erplain]64HAS lHE APPLICANT OR ANY OTHER PERSON OR CORPORATION i.llENTIONEO IN THIS IICENSE APPLICATION,OR ANYONE W H A BENEFICIAL INTEREST IN THE BUSINESS UNDER LICENSE OR TO BE LICENSED. EVER BEENCONVICTED OF A CRIMINAL OFFENSE? _ Yes _ NoA THE ANSWER IS’YES,’ANSWER THE FOLLOWING:Name oI IndividualDate oi B rthStateDescriptron ol offense (specrfrc charge)Lasl Name_t _t _Court of Ju.isdiclionFirsl NameConviction DateMiddle lnitialDrsposilion (fine, penalty etc )Nature oI interest in entity to be licensedB. l( applicable. provide the date the Director ot the N.J. Division of Alcoholic Beverage Conlrolissued an order approvingor disapproving disqualilication remova| _l _l_. (No license may be issued without an orderlrom the Director of the Drvision ol Alcoholic Beverage Control determining no disqualiflcalion or removingdisqualificalion.) (See R S. 33:1-31 2 and N.J A C 13:2’15.)Provide Agency Docket No :[NN]-
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Page 8STATE ASSIGNED LICENSE NUMBERPLEASE TYPE OR PRINT ALL INFORMATIONDOES THE APPLICANT OR ANYONE MENTIONED IN THIS APPLICATION OWE THE STATE OF NEW JERSEY ORTHE UNITED STAIES ANY LICENSE FEE, PENALTY, INTEREST OR ALCOHOLIC BEVERAGE TAX WHICH HASACCRUED PURSUANT TO THE ALCOHOLIC BEVERAGE TAX LAW, THE ALCOHOLIC BEVERAGE LAW OR ANYOIHER NEW JERSEY OR FEDERAL tAW?_Yes _NoHAS THE LICENSE BEEN ISSUED, OR IS IT BEING REQUESTED TO BE ISSUED, FOR A HOTEUMOTEL AS ANEXCEPTION TO THE POPULATION RESTRTCTTON UNDER THE pROVtSIONS OF R S.33:1-12 20?_Yes _NoIF THE ANSWER IS “YES,” IS IT FOR A HOTEL/MOTEL FACILIry OF 50 OR 1OO ROOMS?CHECK ONE 50 ROOI,1S 1OO ROOMS8 3 HAS THE LICENSE BEEN ISSUED. OR 1S IT EEING REOUESTED TO BE ISSUEO. AS AN EXCEPTION TO THE TWOLICENSE LIMITATION LAW (R S. 33:1’12,32) FOR A HOTEUMOTEL. RESTAURANT. BOWLING ALLEY ORINTERNATIONAL AIRPORT? _yes _ NolF THE ANSWER lS”YES,’CHECK ONE OF THE FOL|OW|NG: HOTEUMoTEL- RESTAURANT – BOWLING ALLEY INTERNATIONAL AIRPORTTHE FOLLOWING ARE TO 8E ANSWERED WHEN APPLICATION IS FOR A LICENSE TRANSFER,8,4 LICENSE NUMBER SOUGHT TO BE TRANSFERRED8.5 lF THIS lS A REOUEST FOR A PERSON-TO-PERSON TRANSFER, INSERT NAME(S) OF PERSON (Last Name First),PARTNERSHIP OR CORPORATION CURRENTLY HOLDING THE LICENSE:81828.6LL APPLICANTS ANSWER THE FOLLOWING(Last Name, First Name, Middle lnitial or Corporate Name)IF THIS IS A REOUEST FOR A PLACE,TO.PLACE TRANSFER OF A POCKET LICENSE (NO SITED PREMISES), MARKAN X HERE;IF THIS IS A REOUEST FOR A PLACE-TO”PLACE TRANSFER OF A SITED LICENSE, INSERTTHE ADORESS OF THECURRENT SITE FROM WHICH THE LICENSE IS 10 BE TRANSFERRED.Sl.eel AddressZ,p _THE FOLLOWING ARE TO BE ANSWERED BY APPLICANTS FOR A NEW LICENSE OR A LICENSE TRANSFER.B 7 INSERT THE ANTICIPATED DATES WHEN PUBLIC NOTICE OF APPLICATION WILL 8E PUBLISHED. PUBLICATIONMAY NOT BE SOONER THAN THE DATE OF FILING OF THIS APPLICATION.N um berStreet NameMunicipalityNew JerseyDate of first noticeDate of second noticeB B NAME OF NEWSPAPER TO PUBL SH NOTICE8.9 THE FOLLOWING ARE TO BE ANSWERED BY CORPORATIONS REPORTING A CHANGE OF CORPORATESTRUCTURE WHEREIN A NEW STOCKHOLDER ACOUIRES MORE TI.]AN 1 PERCENT OF THE STOCK OF THELICENSED COIVlPANY (ONE PUBLICATION OF NOTICE REQUIRED).Dale of notice / IName of newspaper publishing noticeTHE FOLLOWING OUESTIONS ARE FOR CLUB LICENSE APPLICANTS ONLY:8,10 HAS THE CLUB BEEN IN ACTIVE OPERATION IN THE STATE OF NEW JERSEY FOR AT LEAST THREE YEARSCONTINUOUSLY I[,4MEDIATELY PRIOR TO THE SUBMISSION OF ITS APPLICATION FOR A LICENSE?_Yes _No8.11 IS THE APPLICANT A CONSTITUENT UNIT, CHARTERED OR OTHERWISE DULY ENFRANCISED CHAPTER ORMEMBER CLUB OF A NATIONAL OR STATE ORDER’_Yes _No812 HAS THE CLUB HAD EXCLUSIVE POSSESSION AND USE OF CLUB QUARTERS FOR THREE CONTINUOUS YEARS?_Yes _No813 DOES THE CLUB HAVE AT LEAST 60 VOTING MEMBERS?Yes No
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ALL APPLICANTS ANSWER THE FOLLOWING9 1 DOES ANY INOIVIDUAI, PARINERSHIPLY OR INOI, coRCTLYPORATION OR ASSOCIATION OTHER THAN THE APPLICANT HAVEIN THE LICENSE APPLIED FOR OR IS THE STOCK OF ANYAN INTEREST DIRECTSTOCKHOLDER HELD IN ESCROW OR PLEDGED IN ANY WAY”YesNoIF THE ANSWER IS “YES,” ANSWER THE FOLLOWING USING A SEPARATE PAGE 9 FOR EACH INDIVIDUAL ORCORPORATION OF INTEREST, ATIACH A SEPARATE PAGE OF EXPLANATION IF MORE SPACE IS NEEDED.Name of lndrvidual (Last Name Firsl) or Corporation(Last Name, Firsl Name, Middle lnitial or Corporate Name)Social Security Number_- _ – — ORNJ Sales Tax Cenr,rcate of Authonty NumoerStreet Add.essNumberStreet NameP.O Box#_ Municipalityzip—Describe Nature of lntereslSlate92DOES ANY INDIVIDUAL, PARTNERSHIP, CORPORATION OR ASSOCIATION HOLD ANY CHATTEL N4ORTGAGE ORCONDITIONAL BILL OF SALE OR OTHER SECURITY INTEREST ON ANY FURNITURE, FIXTURES, GOODS OREQUIPMENT TO BE USED IN CONNECTION WITH THE BUSINESS TO BE OPERATED UNDER THE LICENSEAPPLIED FOR? Yes NoIF THE ANSWER IS “YES.” ANSWER THE FOLLOWING USING A SEPARATE PAGE 9 FOR EACH INDIVIDUAL ORCORPORATION TO BE REPORTED. ATTACH A SEPARATE PAGE OF EXPLANATION IF [.l!ORE SPACE IS NEEDED.Name of lndividual (Last Name Firsl) or Co.poration(Last Name, Firsl Name, Middle lnilial or Corporate Name)Social Securily Number_ – _ – _ ORNJ Sales Tax Certificale of Authorily NumberSlreet Add.essNumbe.Streel NameP.O Box #MunicipalityStalezrp—Describe Nature of lnterest9.3 HAS THE APPLICANT AGREED TO PERMIT ANYONE NOT HAVING AN OWNERSHIP INTEREST IN THE LICENSE TORECEIVE OR AGREED IO PAY ANYONE (BY WAY OF RENT, SALARY OR OTHERWISE) ALL OR ANY PERCENTAGEOF THE GROSS RECEIPIS OR NET PROFIT OR INCOME DERIVED FROM THE BUSINESS TO BE CONDUCTEDUNDER THE LICENSE APPLIED FOR? YeS NoIF THE ANSWER IS’YES,’ANSWER IHE FOLLOWING USING A SEPARATE PAGE 9 FOR EACH INDIVIDUAL ORCORPORATION TO BE REPORTED ATTACH A SEPARATE PAGE OF EXPLANATION IF I,4ORE SPACE IS NEEDED.Name of lndividual (Lasl Name Firsl) or CorporationMiddle lnitia,Last NameSocial Security NumberFirsl NameORNJ Sales Tax Cerlrticate of Authonty NumberStreet Add.essNumberStreel NameP.O.Box#_ Municipalityzip -‘ -Describe Nalure of lnlerestAPPLICANTS THAT ARE SOLE PROPRIETORS OR PARTNERSHIPS GO IO PAGE 1OA CORPORATIONS AND LIMITED LIABILITYCOMPANIES COMPLETE PAGE 1OPAgE 9 PLEASE TYPE OR PRINTALL INFORMATIONSTATE ASSIGNED LICENSE NUMBERStale _
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OUESTIONS TO BE ANSWERED BY CORPORATIONS AND LII\,4ITED LIABILITY COMPANIES ONIY, ANY CORPORATION ORLIMITED LIABILlTY CO[/1PANY THAT IS REPORTED TO HAVE AN INlEREST IN THE EUSINESS TO BE LICENSED. WHETHER THELICENSEE COI4PANY, THE PARENI CORPORATION OF THE LICENSED COMPANY. HOLOING COIVIPANY OR OTHERWISEAFFILIATED IN THE CORPORATE CHAIN, MUST ANSWER IHE FOLLOWING USING A SEPARATE PAGE 1O AND PAGE 1OA FOREACH CORPORATION. ANSWER QUESTIONS ON BOTH PAGE 1O AND PAGE 1OA FOR EACH CORPORATION,10 1 \ame nf rornn,”l,.^10 2 Slreet address of home officeNumberSlreet NameMunicipalityStatezap—10 3104NJ Sales Tax Certificate of Aulhoily NumberIF CORPORATION ADDRESS IN NUMBER 10,2 ABOVE IS OUT OF STATE, REPORT BELOW THE ADDRESS OF ANYOFFICE LOCATION IN NEW JERSEY INSERT N/A IF NONE,Street AddressNumberStreet NametrunicipalilyNew.lerseyztp -10 510.610?10.8ls THE CORPORAT|ON NOW AN EXTSTNG, VAL|D CORPORATION? _ YesDATE CHARTERED OR ]NCORPORATED I I(Lasl Name, First Name, Middle lnitial or Corporation)Slreet AddressNoSTATECE RTIFICATI OF INCORPORATION NUI\,IBERIF NOT INCORPORATED UNDER THE LAWS OF NEW JERSEY, HAS THE CORPORATION RECEIVED ANAUTHOR]ZATION TO CONDUCT BUSINESS IN NEW JERSEY FROM THE NEW JERSEY OFFICE OF THE SECRETARYOF STATE? Yes No10.9 HAS THE CORPORATION CHARTER EVER BEEN REVOKED BY THE OFFICE OF THE SECRETARY OF STATE INNEW JERSEY? Yes NoIF THE ANSWER IS ^YES,” INSERT THE DATE OF REVOCATION, OR IF SUSPENDED, THE BEGINNING AND ENDINGDATE OF THE SUSPENSION,Date of revocationBeginoing dateEnding date1O 1O INSERI THE NAME AND AODRESS OF THE REGISIERED OR AUTHORIZED AGENT IN NEW JERSEY UPON WHOMSERVICE OF PROCESS IN ANY PROCEEDINGS AGAINST THE APPLICANT, PURSUANT TO THE NEW JERSEYALCOHOLIC BEVERAGE LAW, THE ALCOHOLIC EEVERAGE TAX LAW OR PROCEEDINGS IN A STATE OR U.S.DISTRICT COURT, MAY BE MADE,N.meStreet NameN4unicipalrtyNew Jerseyzip –Telephone Number (_)Area Exchange NumberIF THE LICENSED COMPANY IS OWNED BY OTHER CORPORATION(S) OR IS IN A CORPORATE CHAIN. ATTACH ADIAGRAI\I! DEPICTING THE CORPORATE RELATIONSHIPS ANO THE PERCENTAGE OF STOCK INTEREST IN THECOMPANY TO BE LICENSED, OWNED BY OTHER CORPORATIONS OR OTHER NON-CORPORATE ENTITITES(INDIVIDUALS, PARTNERSHIPS, ASSOCIATIONS).10 11Page 10 PLEASE wPE oR PRINT ALL INFoRMATIoNSTATE ASSIGNED LICENSE NUIUBERttNumber
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Page 10ASTATE ASSIGNED LICENSE NUI\4BERPLEASE ryPE OR PRINT ALL INFORMAIIONALL APPLICANTS ANSWER THE FOLLOWING [ADD PAGES AS NECESSARYISOLE OWNERS AND PARTNERSHIPS: Complete this page in full.LIMITED PARTNERSHIPS: All informalion abolrl a general partner or parlners of a limited partnership must be reporled, whether lhegeneral pa.tner is an indivrdual or a co.poratron. A list of lhe names and addresses ol all limited partners must be submitted as anatlachment to this application wilh an identification of lhe percentage of each limited partner as it relales to total ownership of the businessentjly lo be licensedCORPORATIONSi All corporalion applicants or licensees and any corporation thal has an ownership interest in the corporatioo underlicense or lo be licensed musl have been reported on Page 10. lnformation on th,s Page, 10A, will identiiy all offlcers, directors andslockholders holdrng one percent or more of the shares ofthe respective company. Club licenses must lisl names ofoflicers and directgrsand attach a cu.rent membe.ship Ist.***********r****** *r*i**ar***a**i*t***r*****r**r**al**********ti*t****t*r*****:a*****r:rtNAME OF CORPORATION OR CLUB COVERED BY THIS PAGE (COMPLETE ONLY IF APPLICANT OR STOCKHOTDER IS ACORPORATION OR PARTNERSHIP)lName of individual (lasl name ilrsl), stockholder, partner, officer or di.ectorLast NameHome Streel AddressFirst NameMiddle lnilialNumberSlreet NameP.O.Box#_ Municipalityzip —Social Securily Number _ -Home telephone number (_)_-Area ExchangeOtfrce telephone number (AreaExchangeNumber7o of bus,ness owned or controlledCheck posiiion that applies: _ Sole owner – PartnerPresidenl Vice-President – Secretary_ Trustee _ Manager – Agenl_ Beneficiary _ Other (specify)Name of rndividL,al (lasl name first) , stockholder, partne., oaficer or directorStockholderTreasurerExecutor/AdminislratorDireclorReceiverStateDate of Birth _ /NumberNumber of sharesLast NameHome Slreet AddressFirst NameMiddle InitialNumberP.O.Box#_ Municipalityzip -‘ -Home telephone number ( _ )AreaSlreel NameStaleSocial Security Number- – – Date ol BirthExchange NumberOfllce telephone number (- )- -Area ExchangeNumber9/o of business owned or controlledNumber of sharesCheck posrtaon lhat applies_ PresidentTruslee_ Sole owner_ Vice-Presidenl_ [ranager_ Partner_ Secretary_ AgenlSlockholderTreasurerDireclorReceiverExecutor/Administrator_ Benellciary _ Other (specify))_-_
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