Application To Change Managing Officer
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2MISSOURI DEPARTMENT OF PUBLIC SAFETY
DIVISION OF ALCOHOL AND TOBACCO CONTROL
APPLICATION TO CHANGE MANAGING OFFICER
CURRENT LICENSE NUMBERS
BUSINESS STRUCTURE
CORPORATION
LIMITED LIABILITY COMPANY
LIMITED PARTNERSHIP
LEGAL NAME OF ENTITY
DOING BUSINESS AS
PHYSICAL LOCATION ADDRESS OF LICENSED BUSINESS
CITY, STATE, ZIP CODE
MAILING ADDRESS (IF DIFFERENT FROM ABOVE)
BUSINESS TELEPHONE NUMBER
MISSOURI RETAIL SALES TAX NUMBER
IF APPLYING AS A CORPORATION, LLC OR LIMITED PARTNERSHIP, STATE MISSOURI SECRETARY OF STATE FILE NUMBER
DATE OF INCORPORATION OR ORGANIZATION
PLACE OF INCORPORATION (CITY/STATE)
INFORMATION FOR NEW MANAGING OFFICER
LAST NAME
FIRST NAME
MIDDLE INITIAL
DATE OF BIRTH
PLACE OF BIRTH
SOCIAL SECURITY NUMBER
SEX
ATTACH
HOME PHONE NUMBER
E-MAIL ADDRESS
PHOTOGRAPH
OF
CURRENT ADDRESS
CITY
STATE & ZIP CODE
MANAGING OFFICER
APPLICANT
NUMBER OF SHARES OWNED/PERCENTAGE OF MEMBERSHIP INTEREST
IS MANAGING OFFICER APPLICANT A NATURALIZED CITIZEN?
YES
NO
IF YES, LIST THE DATE AND COURT WHICH ADMITTED YOU TO CITIZENSHIP.
CITY, TOWN OR VILLAGE WHERE THE MANAGING OFFICER APPLICANT PAYS TAXES
MANAGING OFFICER APPLICANT IS REGISTERED TO VOTE IN THE FOLLOWING
PRECINCT
CITY
WARD
COUNTY
LIST ADDRESSES FOR THE PREVIOUS TEN YEARS
CITY
STATE & ZIP CODE
DATES LIVED THERE
LIST ADDRESSES FOR THE PREVIOUS TEN YEARS
CITY
STATE & ZIP CODE
DATES LIVED THERE
LIST ADDRESSES FOR THE PREVIOUS TEN YEARS
CITY
STATE & ZIP CODE
DATES LIVED THERE
IMPORTANT
FOLLOWING ITEMS MUST BE SUBMITTED WITH APPLICATION
- One Photograph of managing officer.
- Copy of managing officer’s personal property or real estate tax receipt.
- Copy of managing officer’s voters registration card or certificate.
- Submission of Criminal Record Check issued by the Missouri State Highway Patrol Criminal Records
Division dated within six months preceding the date of the application for the new managing officer.
The record check must be issued by the Missouri Criminal Records Division, P.O. Box 9500,
Jefferson City, MO 65102, (573) 526-6153. Form is available at
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