Form Crf-009 - State Alcohol License Application - 2011

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CRF-009 (Rev. 6/11)
GEORGIA DEPARTMENT OF REVENUE
ALCOHOL & TOBACCO DIVISION
P.O. BOX 49728
Atlanta, GA 30359
Phone: 1 (877) 423-6711
Fax: (404) 417-4901 OR (404) 417-4318
STATE ALCOHOL LICENSE APPLICATION
(RETAIL OR COMSUMPTION ON PREMISES FOR LIQUOR, BEER AND/OR WINE)
(PLEASE PRINT OR TYPE)
IDENTIFICATION SECTION
FOR OFFICE
USE ONLY
LICENSE YEAR FOR WHICH APPLICATION IS MADE:
1
F I
Y
O
U
H
A
V
E
A
S
T
A
T
E
T
A
X
P
A
Y
E
R
D I
E
N
T
F I
E I
R
S (
T
, ) I
E
N
T
E
R
H
E
R
: E
2
3
LEGAL BUSINESS NAME:
4
LOCATION ADDRESS:
SUITE
PHONE NUMBER
5
CITY
STATE
ZIP CODE
NAME OF LICENSEE:
SOCIAL SECURITY NUMBER:
6
IS LICENSEE A CORPORATION?
YES
NO
If “Yes”, name and address of Registered Agent
ALCOHOL INFORMATION SECTION
7
Mailing Address (if different from the Location Address):
CITY:
STATE:
ZIP:
8
TYPE OF LICENSE (Check only one major category that applies)
RETAIL PACKAGE (Check all that apply)
CONSUMPTION ON PREMISE (Pouring) Check all that apply
Beer – Fee $50.00
Beer – Fee $50.00
Wine – Fee $50.00
Wine – Fee $50.00
Liquor – Fee $100.00 + Investigation Fee $100.00
Liquor – Fee $100.00 + Investigation Fee $100.00
HOTEL IN-ROOM SERVICE (Check only one)
–
Beer
Fee $50.00
–
Wine
Fee $50.00
–
Beer and Wine
Fee $100.00
–
Liquor
Fee $100.00 + Investigation Fee $100.00
–
Beer and Liquor
Fee $100.00 + Investigation Fee $100.00
–
Wine and Liquor
Fee $100.00 + Investigation Fee $100.00
–
Beer, Wine and Liquor
Fee $100.00 + Investigation Fee $100.00
9
TYPE OF BUSINESS (Check One)
Hotel In-Room Service
Club
Tavern or Lounge
Convenience Store
Package Store
Restaurant
Grocery
Service Station
Other
10
LOCAL LICENSE ISSUED BY:
(Check Only One)
City of
County of

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