Incorporated City Priority List Liquor License Application Form - Alcohol Beverage Control -Idaho State Police
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1
2Idaho State Police
Alcohol Beverage Control
700 S. Stratford Dr. Ste 115
Meridian, ID 83642
(208) 884-7060
Incorporated City Priority List Liquor License Application
. City and County for the proposed license: _____________________________________
1
□
2. License Type and Fees
Application Fee Enclosed $ ____________
Business must be located within the incorporated city limits
of the city being applied
for.
3.
Applicant Information
: ______________________________________________________________
Applicant Name
(Applicant Name: Individual(s), Corporation, LLC or Partnership)
Mailing Address: _______________________________________________________________________
City, State, Zip: _______________________________________________________________________
Daytime Telephone: _____________________ Nighttime Telephone: ____________________________
Federal or State Tax I.D. Number for Corp., LLC or Partnership: _______________________________
SSN for Individual(s)/Sole Proprietor(s): ___________________________________
4.
List sole proprietor(s) or all partners, corporate officers, directors, ten primary stockholders,
LLC/LLP members/partners of the applicant.
Attach a separate sheet of paper following the format below.
Name: ______________________________________ Address: __________________________________________
Title: _____________________ SSN: ______________________________ DoB: ____________________________
Idaho Resident: (Y/N) _________________________ If ‘YES’ length of residency: __________________________
5. Read the following, Sign and have notarized.
The applicant hereby swears or affirms under oath that the applicant is the bona fide owner of the business which will be engaged in
the sale or dispensing of liquor by the drink, beer and/or wine by the bottle and/or glass upon issuance of the license. The applicant
hereby affirms that the applicant is eligible and has none of the disqualifications for a license as provided by Title 23, Chapter 9, 10,
11, 13 and 14, Idaho Code or any amendments thereto. Applicant further acknowledges that they and/or each person indicated on
this application or attachments understand that state law controlling alcohol beverage licensing is found at Title 23, Idaho Code and
the Alcohol Beverage Control administrative rules found at IDAPA .05.01, and that any violation of these laws or rules can result in
criminal and/or administrative sanctions, and up to and including license revocation.
I/we, the applicant of this license, have read all of the above and declare under penalty of perjury that the information that I/we
have provided is true and correct to the best of my/our knowledge.
____________________________________ ____________________ _______________
Authorized Agent or Applicant’s Signature
Title
Date
______________________________________________________
Authorized Agent/Applicant’s Printed Name
Subscribed and sworn to before me this ______ day of ______________, 20____.
__________________________________________
Notary Public
Residing At_____________________________________
(Seal)
: _________________________
My Commission Expires
EH 10.02-09
Rev 03/2013
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