Form At-107 - Application For Sports Club Permit For Alcohol Beverage License (Page 4 of 4) in pdf

Form At-107 - Application For Sports Club Permit For Alcohol Beverage License Page 4

SCHEDULE FOR APPOINTMENT OF AGENT

Each club applying for a license to sell fermented malt beverages and/or intoxicating liquor must appoint an agent pursuant to sec. 125.04(6),

Wi. Stats. The following questions must be answered by the agent, the appointment must be signed by the president and secretary of the

club, and the appointment must be approved by the proper local official.

NAME

DATE OF BIRTH

STREET ADDRESS

STATE

ZIP

CITY

NAME OF CLUB

OCCUPATION

ARE YOU OF LEGAL DRINKING AGE?

YES

HAVE YOU BEEN A CONTINUOUS RESIDENT OF WISCONSIN FOR AT LEAST 90 DAYS PRIOR TO THE DATE OF APPOINTMENT AS AGENT?

YES

HAVE YOU EVER BEEN CONVICTED OF A VIOLATION OF FEDERAL LAW?

YES

STATE LAW?

YES

LOCAL ORDINANCE?

YES

EXPLAIN FULLY ANY QUESTION ANSWERED YES.

I DECLARE UNDER THE PENALTIES OF LAW THAT THE ABOVE INFORMATION IS TRUE, CORRECT AND COMPLETE.

SIGNATURE

DATE

AGENT SIGN

HERE

APPOINTMENT OF AGENT

APPOINTS

AS AGENT IN ACCORDANCE WITH SECTION 125.04(6), WISCONSIN STATUTES, SUBJECT TO THE APPROVAL OF THE DEPARTMENT OF REVENUE.

SIGNATURE

DATE

PRESIDENT/MEMBER

SIGN HERE

SIGNATURE

DATE

SECRETARY/MEMBER

SIGN HERE

ACCEPTANCE BY AGENT

I HEREBY ACCEPT APPOINTMENT AS AGENT FOR

AND ASSUME FULL

RESPONSIBILITY FOR THE CONDUCT OF THE BUSINESS RELATIVE TO FERMENTED MALT BEVERAGES AND INTOXICATING LIQUOR.

SIGNATURE

DATE

AGENT SIGN

HERE

APPROVAL OF AGENT

THE AGENT APPOINTED ABOVE MUST BE APPROVED AS FOLLOWS:

THE APPOINTMENT OF THE ABOVE AGENT IS HEREWITH APPROVED.

(A)

IN TOWNS BY THE TOWN CHAIRMAN

(B)

IN VILLAGES BY THE PRESIDENT OF THE VILLAGE

(C)

IN CITIES BY THE CHIEF OF POLICE

WI,

(MUNICIPALITY)

(DATE)

(SIGNATURE OF OFFICIAL)

TITLE

Form At-107 - Application For Sports Club Permit For Alcohol Beverage License Page 4

Related Articles

Related forms

Related Categories