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RENEWAL ALCOHOL BEVERAGE LICENSE APPLICATION

Applicant’s Wisconsin

Seller’s Permit Number:

Submit to municipal clerk. Read instructions on reverse side.

Federal Employer Identification

Number (FEIN):

For the license period beginning:

ending:

LICENSE REQUESTED

(MM DD YYYY)

TYPE

FEE

Town of

}

Class A beer

TO THE GOVERNING BODY of the:

Village of

Class B beer

City of

Class C wine

County of

Aldermanic Dist. No.

(if required by ordinance)

Class A liquor

Class B liquor

CHECK ONE

Individual

Partnership

Limited Liability Company

Reserve Class B liquor $

Corporation/Nonprofit Organization

Publication fee

Complete A or B. All must complete C.

TOTAL FEE

Individual or Partnership:

Full Name(s) (Last, First and Middle Name)

Home Address

Post Office & Zip Code

Full Name of Corporation/Nonprofit Organization/Limited Liability Company

Address of Corporation/Limited Liability Company (if different from licensed premises)

All Officer(s) Director(s) and Agent of Corporation and Members/Managers and Agent of Limited Liability Company:

Title

Name (Inc. Middle Name)

Home Address

Post Office & Zip Code

President/Member

Vice President/Member

Secretary/Member

Treasurer/Member

Agent

Directors/Managers

C. 1. Trade Name

Business Phone Number

2. Address of Premises

Post Office & Zip Code

3. Does the applicant understand that they must purchase alcohol beverages only from Wisconsin wholesalers, breweries and brewpubs?

Yes

4. Premises description: Describe building or buildings where alcohol beverages are to be sold and stored. The applicant must

include all rooms including living quarters, if used, for the sales, service, and/or storage of alcohol beverages and records.

(Alcohol beverages may be sold and stored only on the premises described.)

5. Legal description (omit if street address is given above):

6. a. Since filing of the last application, has the named licensee, any member of a partnership licensee, or any member, officer,

director, manager or agent for either a limited liability company licensee, corporation licensee, or nonprofit organization

licensee been convicted of any offenses (excluding traffic offenses not related to alcohol) for violation of any federal

laws, any Wisconsin laws, any laws of other states, or ordinances of any county or municipality? If yes, complete reverse side

Yes

b. Are charges for any offenses presently pending (excluding traffic offenses not related to alcohol) against the named

licensee or any other persons affiliated with this license? If yes, explain fully on reverse side . . . . . . . . . . . . . . . . . . . . . . . .

Yes

7. Except for questions 6a and 6b, have there been any changes in the answers to the questions as submitted by you on your

last application for this license? If yes, explain.

Yes

8. Was the profit or loss from the sale of alcohol beverages for the previous year reported on the Wisconsin Income or

Franchise Tax return of the licensee? If not, explain.

Yes

9. Does the applicant understand a Wisconsin Seller’s Permit must be applied for and issued in the same name as that shown

under Section A or B above? [phone (608) 266-2776] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

10. Does the applicant understand that alcohol beverage invoices must be kept at the licensed premises for 2 years from the

date of invoice and made available for inspection by law enforcement? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

11. Is the applicant indebted to any wholesaler beyond 15 days for beer or 30 days for liquor? . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

READ CAREFULLY BEFORE SIGNING: Under penalty provided by law, the applicant states that each of the above questions has been truthfully answered to the

best of the knowledge of the signers. Signers agree to operate this business according to law and that the rights and responsibilities conferred by the license(s),

if granted, will not be assigned to another. (Individual applicants and each member of a partnership applicant must sign; corporate officer(s), members/managers

of Limited Liability Companies must sign.)

SUBSCRIBED AND SWORN TO BEFORE ME

this

day of

, 20

(Officer of Corporation/Member/Manager of Limited Liability Company /Partner/Individual)

(Clerk/Notary Publc)

(Officer of Corporation/Member/Manager of Limited Liability Company /Partner)

My commission expires

(Additional Partner(s)/Member/Manager of Limited Liability Company if Any)

TO BE COMPLETED BY CLERK

Date received and filed with municipal clerk