Application For Alcoholic Beverage Control Manufacturer License(S) - Nys Liquor Authority Page 14

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OFFICE USE ONLY
14
Date ________________
Original
Amended
Print YOUR Name
_________________________________________________________
5. LICENSE HISTORY / AFFILIATIONS
5(d) Other than as itemized in 5(c) above, have you ever applied in New York State
or anywhere for a license or permit to traffic in alcoholic beverages, including
Yes
No
any application as a partnership, limited partnership, limited liability entity or
corporation in which you are/were a principal?
If YES, provide information below:
Name of Applicant
Address of Premises
Disposition
Date of Filing
License Serial Number
Address of Premises
Name of Applicant
Disposition
Date of Filing
License Serial Number
Address of Premises
Name of Applicant
License Serial Number
Disposition
Date of Filing
Name of Applicant
Address of Premises
Disposition
Date of Filing
License Serial Number
5(e) Has a license or permit listed above been REVOKED, CANCELLED or otherwise
Yes
Yes
No
Involuntarily Terminated?
If YES, provide information below:
5(f) Are you a police commissioner or law enforcement / police officer?
Yes
Yes
No
If YES, provide details
Page 4 of 5

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