Sd Eform-1902 V2 - South Dakota Alcoholic Beverage Carrier License Application Page 2

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Company supplement information
(For corporate/partnership/LP/LLC applicants)
If supplement unchanged from last year check this box and sign below.
Affidavit
State of South Dakota
)
:ss
County of
)
We, the undersigned, being first duly sworn upon oath, supply the following information:
Name of corporation/partnership/LP/LLC___________________________________________________________________________
Address of office and principal place of business of corporation/partnership/LP/LLC__________________________________________
Date of incorporation _________________________________________________________________________________________
Date of last report filed with Secretary of State ______________________________________________________________________
Are all managing officers of this corporation/partnership/LP/LLC of good moral character? _____________________________________
Have any of the managing officers of this corporation/partnership/LP/LLC ever been convicted of a felony? ________________________
Name, title of office, occupation and address of each of the officers/owners of the corporation, partnership, LP or LLC:
Name
Office
Address
Occupation
Name, address and occupation of each of the directors of the corporation:
Name
Address
Occupation
Name and address of each of the stockholders and percentage of shares owned or held by each:
Name
Address
Percentage of Shares
Name of any officers, directors, partners or stockholders of applicant having a financial interest or capital stock in any other retail liquor outlet:
Name
Type of License, Financial Interest Held, and Address of Retail Outlet
Where and with whom are all company records kept, such as charter, by-laws, minutes, accounts, notes payable, and notes and accounts
receivable, etc?
With signature the applicant agrees to the following:
That the applicant company will comply with all provisions of ARSD chapter No. 64:75:02 of the Department of Revenue,
relating to the transfer of stock and prior approval of the transfer of such stock by the Secretary of Revenue and violation of any of the provi-
sions of said regulation or failure to comply therewith, whether by the undersigned corporation, partnership/LP/LLC or by any stockholder
thereof, or by anyone interested in said company, shall constitute cause for revocation or suspension of any license issued pursuant to and in
reliance on this application, or for refusal to renew such license upon expiration thereof.
We the undersigned officers and directors of the applicant company acknowledge that the within supplement application form is true and
correct in every respect and that there exists no financial arrangement concerning this or any other alcoholic beverage license than that expressly
set forth above. If company stock is to be transferred we ask for approval of such voluntary stock transfer.
Signature of Authorized Officer/Director/Partner ______________________________________________________________________
Subscribed and sworn to before me this __________ of ________________________, _________________ County, State of South Dakota.
My commission expires __________________________
______________________________________________
(Notary Public)
PRINT FOR MAILING
CLEAR FORM

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