Form 39 - Liquor And/or Gambling - Short Form printable pdf download

State of Montana

Form 39

Liquor and/or Gambling Short Form

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

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______________________________________

Authorization

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

application.

Signature of Licensee/Authorized Agent _____________________________________________ Date ______________________

Print Full Name of Licensee/Authorized Agent ___________________________________________________________________

Form 39 Revised 01/2013

Form 39 - Liquor And/or Gambling - Short Form