Sd Eform-0873 V6 - Uniform Alcoholic Beverage License Application

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SD EForm - 0873
Complete and use the button at the end to print for mailing.
Date Recieved_______________________
License No.__________________________
Date Issued_________________________
Uniform Alcoholic Beverage License Application
Mail this copy to: Department of Revenue, Special Tax Division 445 East Capitol Ave Pierre, SD 57501-3100.
A. Owner Name and Address
B. Business Name and Address
Owner’s Telephone #:
Business Telephone #:
D. Legal description of licensed premise:
C. Indicate the class of license being applied for
(submit separate application for each class of license).
Retail (on-sale) Liquor
Retail (on-sale) Liquor - Restaurant
Retail (on-off sale) Wine
Package (off-sale) Liquor
Have you ever been convicted of a felony? [ ] Yes [ ] No
Retail (on-off sale) Malt Beverage
Retail (on-off sale) Malt Beverage & SD Farm Wine
Do you own [ ] or lease [ ] this property? (Check one)
Package (off sale) Malt Beverage
Package (off sale) Malt Beverage & SD Farm Wine
E. State Sales Tax Number:________________________________
Other (please classify)
Transfer Fee $150.00
F. Remember to obtain a Federal Alcohol Stamp, for help call TTB
at 1-800-937-8864.
Number of other Package Liquor Licenses held: _________
Number of other On-sale Liquor Licenses held: _________
G. New license?_____ Transfer? ($150)_____ Re-issuance?_____
Is this License in active use?
[ ] Yes [ ] No
CERTIFICATE: The undersigned applicant certifies under the penalties of perjury that all statements provided herein are true and correct;
that the said applicant complies with all of the statutory requirements for the class of license being applied for and in addition agrees to
permit agents of the Department of Revenue access to the licensed premises and records as provided in SDCL 35-2-2.1, and agrees this
application shall constitute a contract between applicant and the State of South Dakota entitling the same or any peace officers to inspect
the premises, books and records at any time for the purpose of enforcing the provisions of Title 35 SDCL, as amended.
Signed this _____ day of _____________________ Signature _________________________________________
Any Application required to be submitted to a local governing board must be signed in the presence of the city or county auditor, the town clerk
or notary public. This applies to ALL applications EXCEPT the following: distillers, manufacturers, wholesalers, municipalities, airports,
solicitors, dispensers, carriers, transportation companies, and farm wineries.
Place of business is located in a municipality? [ ] Yes [ ] No County: __________________________
This application was subscribed and sworn to before me this ________ day of ______________________
Approving Officer’s Telephone number ___________________ Signature: _______________________________________________
APPROVAL OF LOCAL GOVERNING BODY – Notice of hearing was published on ____________________. Public hearing on the
application was held ____________________, not less than SEVEN (7) days after official publication. The governing body by majority
vote recommends the approval and granting of this license and certifies that requirements as to location and suitability of premises and
applicant have been reviewed and conform to the requirements of local and South Dakota law.
Amount of fee collected with application $_____________
Application approved for Sunday on-sale operation? [ ] Yes [ ] No
Amount of fee retained $___________________________
Are real property taxes paid to date? [ ] Yes [ ] No
Forwarded with application $ _______________________
Ineligible for video lottery [ ]
Number of video lottery terminals on licensed premise: _____________
For Local Government Use
(State Use)
Sales tax approval_________________
Date ____________________
(Seal) _______________________________________
Mayor or Chairman
If disapproved, endorse reason thereon and return to applicant
Please complete reverse side


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