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DLLC USE ONLY State of Arizona Department of Liquor Licenses and Control 800 W. Washington 5th Floor Phoenix, AZ 85007 (602) 542-5141 Date Processed: CSR: 60th Day: 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 Check the appropriate boxes SECTION 2 Agent Change Complete Sections 1,2,3,4,5 & 7 Acquisition of Control Complete Sections 1,2, 3 & 7 Restructure Complete Sections 1,2,3,6 & 7 (COMPLETE THIS SECTION FOR AGENT CHANGE, ACQUISITION OF CONTROL OR RESTRUCTURE) (EXISTING AGENT OR NEW AGENT) Last First Middle Liquor License # 1. Name: __________________________________________________________________________________ ______________________________ 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) (Do not use P.O. Box Number) 4. Business Location Address: _______________________________________________________________________________________________ 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: __________________________________ City State Zip 7. Mailing Address: ________________________________________________________________________________________________________ 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 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. (COMPLETE THIS SECTION FOR AGENT CHANGE, ACQUISITION OF CONTROL OR RESTRUCTURE) New 1. List all Controlling Persons to be disclosed, current and new. Last First Middle Title Address City State Zip (ATTACH ADDITIONAL SHEET(S) IF NECESSARY) New 2. List stockholders, percentage owners and/or Controlling Members owning 10% or more Last First Middle % Owned Address City State Zip 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 American LegalNet, Inc. www.FormsWorkFlow.com (ATTACH ADDITIONAL SHEET(S) IF NECESSARY) SECTION 4 (COMPLETE THIS SECTION FOR AGENT CHANGE) 1. As an Agent, will you be physically present and operating the licensed premise? Yes No If you answered YES, you must provide a copy of your Basic and Management Training Certificate obtained from a Department approved Liquor Law training provider BEFORE YOUR APPLICATION FOR AGENT ACQUISITION OF CONTROL OR RESTRUCTURE CAN BE SUBMITTED. If you answered NO, go to question 2. 2. Is there a current Manager at this license premises disclosed to the Department with the current Basic and Management Training Certificate? Yes No If yes, Name of current Manager: ____________________________________________________________________________________________ Last First Middle Basic Training Yes No Management Training Yes No If "NO" for 1 and 2, a Manager with a current Basic and Management Training Certificate obtained from a Department approved Liquor Law training provider must be submitted within 30 days after filing the application for Agent Change, Acquisition of Control or Restructure. SECTION 5 To be completed by the INDIVIDUAL OR EXISTING AGENT OR CORPORATE OFFICER OR L.L.C. CONTROLLING MEMBER: (COMPLETE THIS SECTION FOR AGENT CHANGE) 1. License # ___________________________ 2. Current Agent Name: ___________________________________________________________________________________________ (Exactly as it appears on license) Last First Middle I, (Print full name) _________________________________________, hereby consent to the appointment of Agent for this license. I agree to immediately assign a new Agent in the event that I am unable to discharge the duties of Agent for this license. I have not been convicted of a felony in the last five (5) years. X (Controlling Person/Existing Agent) ____ State of _____________________County of _____________________ The foregoing instrument was acknowledged before me this My commission expires on: ________________________ ____________ of _____________________, ___________ Day Month Signature of NOTARY PUBLIC Year _______________________________________________ SECTION 6 Is there more than one licensed premises involved? YES NO If YES, SEPARATE APPLICATIONS must be filed and fees paid for each license/location. Type of current ownership: Type of new ownership: (COMPLETE THIS SECTION FOR RESTRUCTURE) J.T.W.R.O.S. INDIVIDUAL PARTNERSHIP CORPORATION LIMITED LIABILITY CO. MANAGEMENT CO. TRIBE TRUST OTHER (Explain) ______________________________________ J.T.W.R.O.S. INDIVIDUAL PARTNERSHIP CORPORATION LIMITED LIABILITY CO. MANAGEMENT CO. TRIBE TRUST OTHER (Explain) _______________________________________ SECTION 7 To be completed by Controlling Person or existing Agent (if no agent changes) OR NEW Agent if applying for Agent change as listed in Section 2 Question 1. I, (Print full name) _________________________________________, hereby declare that I am the APPLICANT filing this application. I ha