Form 39 - Liquor And/or Gambling - Short Form


State of Montana
Form 39
Liquor and/or Gambling Short Form
Check the Appropriate Box to Designate the Purpose of this Application
Check the Appropriate Box to Designate the Purpose of this Application
The use of this short application is limited to changes in the type of business entity, for example sole proprietor to corporation; or
an increase of current ownership parties from under 10% to over 10% interest, but no other changes to the licensee or licensed
entity are made and a transfer of a license from one location to another, but no other changes to the licensee or licensed entity are
made. NOTE: An ownership interest in a licensed gambling and/or liquor operation may not be transferred to a complete
stranger to the license (someone not already listed and approved as an owner in the licensed operation) unless a new
Alcoholic Beverage/Gambling Operator Combined License Application reflecting the proposed transfer is sent to and
approved by the divisions. Although this application is a short form, the change of entity type or the increase of ownership needs
to be published once a week for two consecutive weeks and the public has the right to protest. See the attached pages for a
checklist of the documents and information that will be required for each transaction type.
Entity Type Change
Increase of current ownership interest from less than 10% ownership to over 10% ownership
Transfer of Location (GOA and/or ONP only; Gambling Manufacturer/Distributor/Route Operator’s use Form 37)
Explain briefly the reason for this application:
Processing Fee: $200
Fingerprint Fee: $27.25 per set (two) when required. (See individual transaction type.)
General Information
General Information
Account ID _______________________ FEIN ____________________ Liquor License No. _______________________
Name of Licensee _________________________________________________________________________________________
Business/Trade Name ______________________________________________________________________________________
Mailing Address___________________________________________________________________________________________
Address of Licensed Premise ________________________________________________________________________________
City, State, Zip____________________________________________________________________________________________
Business Phone_____________ Cell Phone ________________
Email Address______________________________________
I affirm I am authorized to make this application for the applicant and that the answers contained herein are true and complete. If
this application or attachments contain false information, I understand I may be subject to the criminal penalties of Mont. Code Ann.
§ 45-7-202, 45-7-203, 45-7-208, 16-4-402 and/or revocation of any gambling and/or liquor licenses granted pursuant to this
Signature of Licensee/Authorized Agent _____________________________________________ Date ______________________
Print Full Name of Licensee/Authorized Agent ___________________________________________________________________
Form 39 Revised 01/2013


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