Renewals In Connection With The Nys Liquor Authority Page 2

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Form 3
CB#4 SLA RENEWAL QUESTIONAIRRE
Applicant Information & Legal Representation
_______________________________________
_____________________________
1. Applicant
d/b/a
________________________________________________________________________________
2. Street Address ______________________________cross streets__________________________
3. Owner/contact__________________________________________telephone#________________
Fax #_____________________________email___________________________________________
4. Legal Firm/Contact________________________________________________________________
telephone # __________________fax #__________________ email __________________________
5. Landlord/Name/Contact___________________________________telephone#________________
Fax # ______________________email _________________________________________________
Application Status (answer appropriate questions only)
6. Status is this a transfer license request? _______yes
__________no
Are there any operational changes associated with this request ____yes ____no
Transfer -Prior License No.___________________ Expiration Date___________________
Operational Changes- Current License No._____________ Expiration Date___________________
Describe changes- include: hours, service, occupancy, ownership, clientele, and other relevant info
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
7. NYS- License Authority (SLA): Filed: Y/N if yes- is a copy attached (Y/N). If not when will copy
be sent to CB#4___________? Has a hearing date been set? (Y/N)-If known, date of
hearing___________________________________________________________________________
If No – When will SLA application be filed? ______________________________________________
8. Public Interest: 500 foot hearing required? Y/ N /NA
What is the proximity to nearest Place of Worship? ________________________________________
_________________________________________________________________________________

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