Ohio Department Of Commerce - Limited Liability Company Disclosure Form

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FOR OFFICE USE ONLY

OHIO DEPARTMENT OF COMMERCE - DIVISION OF LIQUOR CONTROL

6606 Tussing Road, P.O. Box 4005, Reynoldsburg, Ohio 43068-9005

NEW

TRANSFER

REN

Telephone: (614) 644-2360 -

PERMIT #

LIMITED LIABILITY COMPANY DISCLOSURE FORM

(This form must accompany all applications of an LLC business entity)

SECTION A.

Name of Limited Liability Company

DBA Name

Permit Premises Address

City, State

Zip Code

Tax Identification No. (TIN)

Township, if in Unincorporated Area

Address:

Limited Liability Company ("LLC") - Chapter 1705 Ohio Revised Code. Indicate below the managing members, LLC Officers, and all persons

with a 5% or greater membership or voting interest, and attach a copy of the Articles of Organization filed with the Ohio Secretary of State.

Please be advised that any social security numbers provided to the Division of Liquor Control in this application may be released to the Ohio

Department of Public Safety, the Ohio Department of Taxation, the Ohio Attorney General, or to any other state or local law enforcement

agency if the agency requests the social security number to conduct an investigation, implement an enforcement action, or collect taxes.

SECTION B.

List the top five (5) officers of the captioned business. If an office is NOT held, please indicate by writing NONE.

EACH OFFICER LISTED BELOW MUST HAVE A BACKGROUND CHECK PERFORMED BY BCI&I AND SUBMIT A PERSONAL HISTORY

BACKGROUND FORM. PLEASE READ “BACKGROUND CHECK INFORMATION” DLC4191.

SOCIAL SECURITY NUMBER

BIRTHDATE

NAME OF OFFICER

1) CEO

2) President

3) Vice-President

4) Secretary

5) Treasurer

SECTION C.

List the managing members and all persons with a 5% or greater membership or voting interest in the LLC.

THE INDIVIDUALS LISTED BELOW MUST HAVE A BACKGROUND CHECK PERFORMED BY BCI&I AND SUBMIT A

INTEREST

PERSONAL HISTORY BACKGROUND FORM. PLEASE READ “BACKGROUND CHECK INFORMATION” DLC4191.

1) Name

Social Security No. (if individual)

Check All That Apply

Managing Member

Residence Address

Tax Identification No. (if applicable)

Voting interest

Telephone No.

City and State

Membership interest

Birthdate

Zip Code

2) Name

Social Security No. (if individual)

Check All That Apply

Managing Member

Residence Address

Tax Identification No. (if applicable)

Voting interest

City and State

Telephone No.

Membership interest

Birthdate

Zip Code

(PLEASE SEE REVERSE SIDE SHOULD YOU NEED ADDITIONAL SPACE)

STATE OF OHIO, ___________________________________________ COUNTY ss,

I, ____________________________________________________being first duly sworn, according to law, deposes and says that he/she is (Title) _____________________

of the ______________________________________________, a business duly authorized by law to do business in the State of Ohio, and that the statements made in the

forgoing affidavit are true.

(Signature) ___________________________________________________ (Print Name and Title) __________________________________________________________

Sworn to and subscribed in my presence this __________________ day of _____________________________________________________, _________________________

_____________________________________________________________

(Notary Public)

(Notary Expiration)

DLC 4032

EOE/ADA SERVICE PROVIDER

FOR TTY USERS DIAL 1-800-750-0750

REV. 08/2015