Arizona > Statewide > Liquor Licenses And Control
Application For Agent Change Acquisition Of Control LIC0102 - Arizona
| Application For Agent Change Acquisition Of Control Form. This is a Arizona form and can be used in Liquor Licenses And Control Statewide . |
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ARIZONA DEPARTMENT OF LIQUOR LICENSES & CONTROL 800 W Washington 5th Floor Phoenix AZ 85007-2934 www.azliquor.gov (602) 542-5141 APPLICATION FOR AGENT CHANGE - ACQUISITION OF CONTROL - RESTRUCTURE Check Appropriate Box Agent Change Complete Sections 1,2,3,4,6 (See Note 1 on back) Acquisition of Control Complete Sections 1,2, (3,4 if changing Agent), 6 Restructure Complete Sections 1,2,(3,4 if changing Agent) ,5,6 (See Note 2 on back) SECTION 1 (COMPLETE THIS SECTION FOR AGENT CHANGE, ACQUISITION OF CONTROL OR RESTRUCTURE) 1. Name (INDIVIDUAL OR EXISTING AGENT (if no agent change) OR NEW AGENT OR CORPORATE OFFICER OR L.L.C. CONTROLLING MEMBER) Last First Middle Liquor License # Corp. File #: 2. Corporation L.L.C. N/A: (Exactly as it appears on Articles of Inc. or Articles of Org.) 3. Business Name: (Exactly as it appears on license) 4. Business 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? 6. Mailing Address: City Yes No State Zip 7. Business Phone: (______) ________________________ Residence Phone: (_____) 8. Does this transaction involve the sale of any portion of the corporate stock? YES NO N/A If yes, submit a certified copy of minutes. 9. Has there been any change of officers? YES NO N/A If yes, submit a certified copy of minutes. SECTION 2 (COMPLETE THIS SECTION FOR AGENT CHANGE, ACQUISITION OF CONTROL OR RESTRUCTURE) Each person listed in Section II must submit a personal questionnaire (Form LIC0101) and a Department approved fingerprint card which may be obtained at the Dept. A person appearing in both lists need only submit one questionnaire and fingerprint card. 1. List individual owner or partners or all directors, officers in corp., members in LLC: Last First Middle Title Residence Address City State Zip (ATTACH ADDITIONAL SHEET(S) IF NECESSARY) 2. List stockholders or controlling members owning 10% or more of Corp/LLC: Last First Middle % Owned Residence Address City State Zip LIC0102 4/2009 (ATTACH ADDITIONAL SHEET(S) IF NECESSARY) Disabled individuals requiring special accommodations please call the Department Date Received _________________ CSR _________________________ American LegalNet, Inc. www.FormsWorkFlow.com SECTION 3 (COMPLETE THIS SECTION FOR AGENT CHANGE ) 1. If the corporation/L.L.C. is owned by another entity, ATTACH AN OWNERSHIP AND DIRECTOR / OFFICER / MEMBER DISCLOSURE for the parent entity. Attach additional sheets as necessary in order to disclose real people. As an Agent, will you be physically present and operating the licensed premises? YES NO If you answered YES, you must provide proof of attendance of a Department approved Liquor Law Training Course within the last five years before your application for Agent can be submitted. If "no" a manager with approved training must be submitted. SECTION 4 (COMPLETE THIS SECTION FOR AGENT CHANGE) To be completed by the INDIVIDUAL OR EXISTING AGENT OR CORPORATE OFFICER OR L.L.C. CONTROLLING MEMBER: 1. License Number: ____________________________ 2. Current Licensee or Agent: (Exactly as it appears on license) Last Date of last renewal: First Middle I, _________________________________________________, hereby consent to the agent appointment named herein and (Print full name) agree to immediately assign a new agent in the event of the death, resignation, or discharge of this agent. I also understand that if the background report shows that I, the corporation, or any officer, director, member, or stockholder have been convicted of a felony in the past five (5) years, I will immediately surrender the license to the Arizona Department of Liquor Licenses and Control and hereby waive all rights to appeal such action. State of__________________County of X______________________________________________ The foregoing instrument was acknowledged before me this (Signature of INDIVIDUAL/ CORPORATE/CLUB OFFICER/MEMBER) ________day of ____________________, Day Month (Signature of NOTARY PUBLIC) Year My commission expires on: SECTION 5 (COMPLETE THIS SECTION FOR RESTRUCTURE) Is there more than one licensed premises involved? paid for each license/location. Type of current ownership: J.T.W.R.O.S. INDIVIDU AL PARTNERSHIP CORPORATION LIMITED LIABILITY CO. TRUST OTHER Explain SECTION 6 YES NO If yes, SEPARATE APPLICATIONS must be filed and fees Type of new ownership: J.T.W.R.O.S. INDIVIDUAL PARTNERSHIP CORPORATION LIMITED LIABILITY CO. TRUST OTHER Explain (COMPLETE THIS SECTION FOR AGENT CHANGE, ACQUISITION OF CONTROL OR RESTRUCTURE) To be completed by INDIVIDUAL OR EXISTING AGENT (if no agent change) OR NEW AGENT OR CORPORATE OFFICER OR L.L.C. CONTROLLING MEMBER as listed in Question 1 Section 1: I, ______________________________________________, hereby declare that I am the APPLICANT filing this application. (Print full name) have read the application and the contents and all statements are true, correct and complete. State of ________________County of X______________________________________________ The foregoing instrument was acknowledged before me this (Signature of INDIVIDUAL OR AGENT) day of Day Month (Signature of NOTARY PUBLIC) , Year My commission expires on: 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 MUST be submitted with this application (A.R.S. 4-209.A) American LegalNet, Inc. www.FormsWorkFlow.com ARIZONA REVISED STATUTES 4-203.F ACQUISITION OF CONTROL If a person other than those persons originally licensed acquires control over a license or licensee, the person shall file notice of the acquisition with the Director within fifteen business days after such acquisition of control and a list of officers, directors or other controlling persons on a form prescribed by the Director. All officers, directors or other controlling persons shall meet the qualifications for licensure as prescribed by this title. On request, the director shall conduct a preinvestigation prior to the assignment, sale or transfer of control of a license or licensee, the reasonable costs of which, not to exceed one thousand dollars, shall be borne by the applicant. The preinvestigation shall determine whether the qualifications for licensure as prescribed by this title are met. On receipt of notice of an acquisition of control or request of a preinvestigat
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