Form Wld-031 - For Liquor, County Malt Beverage, Limited, Winery Or Microbrewery Page 2
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44. Does any manufacturer, brewer, rectifier, wholesaler, or through a subsidiary affiliate, officer, director or member of any such
firm: W.S. 12-5-401, 12-5-402, 12-5-403
(a) Hold any interest in the license applied for?
YES
NO
(b) Furnish by way of loan or any other money or financial assistance for purposes hereof in your business?
YES
NO
(c) Furnish, give, rent or loan any equipment, fixtures, interior decorations or signs other than standard brewery or
manufacturer's signs?
YES
NO
(d) If you answered YES to any of the above, explain fully and submit any documents in connection therewith:
5. Does applicant have any interest or intent to acquire an interest in any other retail liquor license to be issued by this
licensing authority? W.S. 12-4-103(b)
YES
NO
If "YES", explain:
6. Is applicant a mayor, member of a city or town council, or member of the board of county commissioners within the
jurisdiction of this licensing authority? W.S. 12-4-103(a)(i)
YES
NO
7. Is applicant employed by the State, City or Town, or County as a law enforcement officer, or hold office as a law enforcement
officer through election? W.S. 12-4-103(a)(ii)
YES
NO
RESTAURANT LICENSE: Complete questions 8(a) through 8(c):
8. (a) Have you submitted a valid food service permit upon application? W.S. 12-4-407(a)
YES
NO
(1) Have you held a Limited Retail Liquor License issued prior to May 25, 1979 and are you hereby requesting
conversion to a Restaurant Liquor License? W.S. 12-4-407(d)
YES
NO
(2) If "YES", indicate:
(a) Name of Limited Retail License holder:
(b) Issuing date of Limited Retail License:
(c) Was your dispensing room for alcoholic and/or malt beverages in existence and open for consumption purposes prior to
February 1, 1979? W.S. 12-4-410(b)
YES
NO
N/A
RESORT LICENSE: Complete questions 9(a) through 9(c):
9. (a) Is the actual valuation of the resort complex at least one million dollars, or have you committed or expended at least one
million dollars ($1,000,000.00) on the complex, excluding the value of the land? W.S. 12-4-401(b)(i)
YES
NO
(b) Does the resort complex include a restaurant and a convention facility which will seat at least one hundred (100)
persons? W.S. 12-4-401(b)(ii)
YES
NO
(c) Does the resort complex include motel or hotel accommodations with at least one hundred (100) sleeping rooms? W.S.
12-4-401(b)(iii)
YES
NO
MICROBREWERY AND/OR WINERY LICENSE: Complete questions 10 through 11:
10. Is premise to be co-existent with a retail, restaurant, or resort liquor license? W.S. 12-4-412(b)(iii)
YES
NO
If "YES", please specify type:
Microbrewery
Winery
Retail
Restaurant
Resort
YES
NO
11. (a) Do you self distribute your products?
(b) Do you distribute your products through an existing malt beverage wholesaler?
YES
NO
ORGANIZATION AND/OR CLUB LICENSE: Complete questions 12 through 15 as applicable:
12. FRATERNAL CLUBS W.S. 12-1-101(a)(iii)(B)
(a) The name and address of the grand lodge or national organization is:
(b) Does lodge or fraternal organization hold a charter from a national organization or national grand lodge?
YES
NO
(c) Has the fraternal organization been actively operating in at least thirty-six (36) states?
YES
NO
(d) Has the fraternal organization been actively in existence for at least twenty (20) years?
YES
NO
13. VETERANS CLUBS W.S. 12-1-101(a)(iii)(A):
(a) The name and address of the National Veterans organization is:
(b) Has the Veteran's organization been chartered by the Congress of the United States for patriotic, fraternal or
benevolent purposes?
YES
NO
(c) Is the membership of the Veteran's organization comprised only of Veterans and its duly organized auxiliary?
YES
NO
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