State Form 47 - Application For Renewal Of Alcoholic Beverage Permit printable pdf download

APPLICATION FOR RENEWAL OF

ALCOHOLIC BEVERAGE PERMIT

State Form 47 (R12 / 7-05)

FOR OFFICE USE ONLY

Approved by State Board of Accounts, 2005

Examined by / date

Hearing date

INSTRUCTIONS:

1. Type or print legibly.

2. Submit in duplicate. Include payment

Issue date

3. Application must be received by our office 77 days (11 weeks) before permit expires.

4. Do not complete shaded areas.

New expiration date

STEP 1. GENERAL INFORMATION

Name of applicant as printed on existing permit

Permit Number

Permit Type

Release date

Name of Business (d/b/a)

State Tax I.D. number

Permit expiration date

Business Address (number and street, city, state, ZIP code )

Business Telephone Area / Number

Base fee

(

)

Home Telephone Area / Number

(

)

o Active

o Non-operational / Escrow

Mailing address (number and street, city, state, ZIP code )

Status

Catering

(Attach escrow letter )

Name of Processor

Date of Renewal

Excise District

Local Board

1) Have there been any changes in the existing operation, floor plans, or seating accommodations since you last applied for

o Yes

o No

this permit? (If Yes, attach affidavit of changes and copies of amended floor plan on 8.5" x 11" paper if applicable)

2) Do you consent for the duration of the permit to inspection and search by an enforcement officer, without a warrant or other

o Yes

o No

process, of your licensed premise and vehicles to determine compliance with the provisions of I.C. 7.1?

3) Does the permittee have an interest in any distiller, vintner, farm winery, rectifier, brewer, primary source of supply, or

o Yes

o No

wholesaler permit?

4) Since your last renewal have you been convicted of any misdemeanor or felony? (If Yes, please attach letter with dates,

o Yes

o No

court, conviction, and sentence of conviction)

o Yes

o No

5) Do you have the right to possess (rent, mortgage, or own) the permit premise for the term of the permit?

o Yes

o No

6) Have all your sales taxes and property tax obligations for the past year and those due at this time been paid in full?

o Yes

o No

7) Do you sell tobacco products?

STEP 2. BUSINESS OWNERSHIP

Limited Liability Company

Partnership

Limited Partnership

Club

Check one:

Corporation

Limited Liability Partnership

Sole ownership

CORPORATIONS ONLY

Note: If the ownership has changed (by death, transfer or sale of stock or interest, etc.) since you last applied for renewal,

the processor should be notified at once before completing this section.

Provide the information for the individuals associated with your permit as follows:

Total shares authorized

CLUB - Highest ranking officer and the financial secretary or treasurer

CORPORATION - President, secretary, and all stockholders (list total shares authorized / issued and individual shares held

and percent of shares issued )

Total shares issued

LIMITED LIABILITY COMPANY - All members and percent of interest held

LIMITED PARTNERSHIP / PARTNERSHIP / LIMITED LIABILITY PARTNERSHIP - All partners and percent of interest held

SOLE OWNERSHIP - Owner

SHARES OR

TITLE

NAME AND HOME ADDRESS

*SOC. SEC. NO. & DOB

INTEREST HELD

IF APPLICABLE

SSN

DOB

SSN

DOB

SSN

DOB

SSN

DOB

*Social Security Numbers are required by federal child support law

Enclose an additional sheet if necessary

State Form 47 - Application For Renewal Of Alcoholic Beverage Permit

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