Form At-105 - Application For Airport/public Facility Permit
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4Wisconsin Department of Revenue
DEPARTMENT USE ONLY
Excise Tax Section 6-107
TAX ACCOUNT NUMBER
PO Box 8900
Madison, WI 53708-8900
(608) 261-6435
APPLICATION FOR
DATE OF ISSUANCE
Fax (608) 261-7049
AIRPORT/PUBLIC FACILITY PERMIT
DATE
TELEPHONE NUMBER
BUSINESS TAX NUMBER
FEDERAL EMPLOYER IDENTIFICATION
SOCIAL SECURITY NUMBER (If you do not
NUMBER (FEIN)
have a FEIN number)
(
)
OR
SECTION 1 – To be completed by Chairperson and Clerk of Municipality or County
Under the provisions of Sections 125.51(5)(b) of the Wisconsin Statutes and a resolution passed by the governing body of (municipality)
or (county)
(a copy of which is attached),
application is being made for a “Class B” intoxicating liquor permit for use on the following described premises which is:
OWNED AND OPERATED BY
KNOWN AS
A.
ADDRESS OF PREMISES
LOCATED IN THE: (CHECK ONE)
TOWN
VILLAGE
CITY OF
FROM THE
DAY OF
20
THROUGH THE
DAY OF
20
B.
APPLICANT:
INDIVIDUAL
PARTNERSHIP
CORPORATION
LIMITED LIABILITY COMPANY
INDIVIDUAL OR PARTNERSHIP: (IF A PARTNERSHIP, ALL PARTNERS MUST BE LISTED)
NAME
HOME ADDRESS
NAME
HOME ADDRESS
NAME
HOME ADDRESS
NAME OF CORPORATION/LIMITED LIABILITY COMPANY
STATE AND DATE OF INCORPORATION/REGISTRATION
IS APPLICANT CORPORATION A SUBSIDIARY OF ANY OTHER CORPORATION OR LIMITED LIABILITY COMPANY?
YES
NO
IF YES, INDICATE CORPORATE NAME OR NAME OF LIMITED LIABILITY COMPANY:
OFFICERS AND DIRECTORS – AN AGENT MUST BE APPOINTED.
PRESIDENT/MEMBER
HOME ADDRESS
VICE PRESIDENT/MEMBER
HOME ADDRESS
SECRETARY/MEMBER
HOME ADDRESS
TREASURER/MEMBER
HOME ADDRESS
AGENT
HOME ADDRESS
DESCRIBE THE ROOM(S) OR AREA TO BE LICENSED FOR THE SALE AND STORAGE OF INTOXICATING LIQUORS.
THE ANNUAL FEE IN THE AMOUNT OF $300 IS PAYABLE TO THE WISCONSIN DEPARTMENT OF REVENUE.
DECLARATION
, Chairperson of the governing body of
and
, Clerk of said body, individually and together, declare under penalties of law that
the information provided in this application is true and correct to the best of their knowledge and belief.
CHAIRPERSON
CLERK
DATE
(CONTINUED ON REVERSE SIDE)
AT-105 (R. 11-11)
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