Form Ab-115 - Wisconsin Liquor/wine Permit Application Page 2
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8 4. List name, social security number, home address, and title of all partners or principal LLC members, officers of corporation.
City, State Zip
Name
Street Address
SS#
Title
5. Have you taken over the business of another permittee?
Yes
No
If Yes, give name and address of predecessor.
Permit #
6. Indicate number and date of your:
Number
Date
Federal Basic Permit (attach a copy)
Federal Occupational Tax Stamp
7. Premises Description - Describe buildings where the liquor/wine will be sold and stored. Include service and/or storage of liquor/wine and busi-
ness records. Liquor and wine may only be sold from and stored on the premises described:
8. Square footage of the premises:
Check One:
Property Owned by Applicant
Leased From
9. Contact Person Name:
Telephone Number:
10. Have you applied for, or do you possess or hold any interest directly or indirectly, in a retail license to sell liquor/wine?
Yes
No
If yes, give name and location:
If yes, explain:
11. Do you or does any officer, director, partner, member, or employe have any interest, directly or indirectly, in any other Wisconsin wholesale
liquor permit or any retail liquor license?
Yes
No
If yes, give names and details of interest held.
12. Have you made any arrangement or agreement with any out-of-state liquor/wine manufacturers or distillers for extension of credit beyond the
usual thirty days?
Yes
No
If yes, provide names and details:
13. Does any manufacturer, distiller, or out-of-state liquor business hold an ownership interest, stock, or otherwise in the business submitting this
application?
Yes
No
If yes, provide names and details.
14. Do you lease or rent real property to a Wisconsin retail liquor licensee?
Yes
No
If yes, provide names and details:
15. Do you or an “immediate family member” have “effective control” of a Wisconsin retail liquor licensee? (“Immediate family member” means a spouse,
a brother or sister [whole or half-blood relationship] or lineal descendant or spouse) (“Effective control” means either the power to direct the affairs
of a retail liquor licensee or the actual direction of the affairs of a retail liquor license)
Yes
No
If yes, provide names and details:
16. Are you a member of a group of two or more corporations or limited liability companies, any one of which has “effective control” of a Wisconsin
retail liquor license?
Yes
No
If yes, provide names and details:
17. Will you be the “importer of record” with U.S. Customs of liquor/wine received from outside the United States?
Yes
No
If “yes” you will be required to obtain security (see instructions).
Yes
No
APPOINTMENT OF AGENT
18. To Be Completed By Corporate/LLC Applicants Only –
, is hereby given full authority and control of the premises described in the
application for a permit and of the conduct of all business on the premises pertaining to liquor/wine. Such authority is intended to be broad enough
to comply with all the provisions of sec. 125.04(6), Wis. Stats.
(Signature of Corporation President or Member of a Limited Liability Company)
(Print or Type Name of President /Member)
I accept appointment as agent for the corporation/limited liability company applying for the permit requested on this application.
Date
Signature
Agent Sign Here
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Wisconsin Department of Revenue
AB-115
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