Application For Agent Change - Acquisition Of Control - Restructure - Arizona Department Of Liquor Licenses And Control
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3DLLC USE ONLY
Date Processed:
State of Arizona
Department of Liquor Licenses and Control
CSR:
800 W. Washington 5
Floor
th
Phoenix, AZ 85007
60
Day:
th
(602) 542-5141
APPLICATION FOR AGENT CHANGE – ACQUISITION OF CONTROL –
RESTRUCTURE
NOTE: 1) The fee for an agent change MUST be submitted with this application: $100.00 for the first application and $50.00 for each
additional application, not to exceed $1,000.00. (A.R.S. 4-209.H) NOTE 2) the $100.00 fee for restructure/acquisition of control MUST
be submitted with this application. (A.R.S. 4-209.A)
SECTION 1
Agent Change
Acquisition of Control
Restructure
Check the
Complete Sections 1,2,3,4,5 & 7
Complete Sections 1,2, 3 & 7
Complete Sections 1,2,3,6 & 7
appropriate
boxes
SECTION 2
(COMPLETE THIS SECTION FOR AGENT CHANGE, ACQUISITION OF CONTROL OR RESTRUCTURE)
__________________________________________________________________________________ ______________________________
1. Name:
(EXISTING AGENT OR NEW AGENT)
Last
First
Middle
Liquor License #
2.
_____________________________________________________________
__________________________________
Owner Name:
Corp File #:
(Exactly as it appears on Liquor License)
(If applicable)
3.
________________________________________________________________
Business Name:
Email: ____________________________________
(Exactly as it appears on Liquor License)
_______________________________________________________________________________________________
4. Business Location Address:
(Do not use P.O. Box Number)
City
COUNTY
Zip
5. Is the Business located within the incorporated limits of the above City or Town?
Yes
No
6. Does the Business location address have a street address for a City or Town but is actually in the boundaries of another City, Town or
Tribal Reservation?
Yes
No If Yes, what City, Town or Tribal Reservation is this Business located in: __________________________________
________________________________________________________________________________________________________
7. Mailing Address:
City
State
Zip
8. Business Phone:
____________________________________ Daytime Contact Phone ____________________________________________
9. Does this transaction involve the sale of any portion of the percentage of ownership or corporate stock?
Yes
No If yes,
submit a certified copy of minutes.
10. Has there been any change of Controlling Persons?
Yes
No if yes, submit a copy of the minutes, amended articles of
organization and/or amended operating agreement showing change
SECTION 3
(COMPLETE THIS SECTION FOR AGENT CHANGE, ACQUISITION OF CONTROL OR RESTRUCTURE)
Each new person listed in section III must submit a questionnaire (form LIC0101) and a Department approved fingerprint card which may be
obtained at the Department of Liquor. A Controlling Person already disclosed to the Department is not required to submit a questionnaire.
1.
.
List all Controlling Persons to be disclosed, current and new
New
Last
First
Middle
Title
Address
City
State
Zip
(ATTACH ADDITIONAL SHEET(S) IF NECESSARY)
2.
List stockholders, percentage owners and/or Controlling Members owning 10% or more
New
Last
First
Middle
% Owned
Address
City
State
Zip
(ATTACH ADDITIONAL SHEET(S) IF NECESSARY)
If the ownership is owned by another entity, ATTACH AN OWNERSHIP FLOWCHART SHOWING THE OFFICERS, MEMBERS, CONTROLLING PERSON AND
10% OR MORE OWNERS FOR THE ENTITIES. Attach additional sheets as necessary in order to disclose all persons.
11/18/2015
Page 1 of 3
Individuals requiring ADA accommodations please call (602)542-9027
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