New York > Statewide > Division Of Alcoholic Beverage Control
Application For Alcoholic Beverage Wholesale License 1015 - New York
| Application For Alcoholic Beverage Wholesale License Form. This is a New York form and can be used in Division Of Alcoholic Beverage Control Statewide . |
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OFFICE USE ONLY whlsle-rev10232012 Original Amended Date LICENSE 29 APPLICATION FOR ALCOHOLIC BEVERAGE CONTROL WHOLESALE LICENSE It is not necessary to employ any person, agency or organization to assist you in filing this application. Beware of persons claiming to be able to assist you in securing action on your application. The payment of money or other thing of value for the use of influence, or promise of influence in obtaining a license is a violation of law and offenders will be prosecuted. 1. APPLICANT Name of Applicant: Trade Name(DBA): (see instructions) ** must be provided if premises will be called by any name other than as listed in the "Name of Applicant" Premises Street Address: City: County: Mailing Address (if different than above): City: E-mail address (if available): State: Zip Code: State: Zip Code: Telephone Number of Premises (include area code): 2. CONTACT (if different than applicant) Name of Contact: Office Address: City: State: Zip Code: Attorney Representative Contact Person Telephone Number of Office (include area code): E-mail address (if available): 3. LICENSE TYPE: (see schedule of fees) CODE: 4. TOTAL PAYMENT DUE: 5. Federal Tax ID #: 6. Certificate of Authority Permit# (required only if the license allows for retail privileges): 7. Are there any local option restrictions in this area (DRY, PARTIALLY DRY)? (Answer required only if the license allows for retail privileges) If YES, explain: YES NO DO NOT KNOW continued on next page [OFFICE USE ONLY] DATE FILED: SERIAL #: Page 1 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY whlsle-rev10232012 Original Amended Date 29 8. TO BE FILLED IN ONLY BY SOLE PROPRIETOR OR PARTNERS (attach additional sheets if necessary) Name of Individual / Partner Residence Social Security Date of Birth Name of Individual / Partner Residence Social Security Date of Birth Name of Individual / Partner Residence Social Security Date of Birth Name of Individual / Partner Residence Social Security Date of Birth 9. TO BE FILLED IN ONLY BY CORPORATION OR LLC/LLP APPLICANTS (attach additional sheets if necessary) List the names and address or Principals (Stockholders, Officers, Directors, LLC Members/Managers, LLP Partners) Name of Principal Residence Social Security #: Title No. of Shares if Corporation or % of ownership if LLC or Partnership Date of Birth Name of Principal Residence Social Security #: Title No. of Shares if Corporation or % of ownership if LLC or Partnership Date of Birth Name of Principal Residence Social Security #: Title No. of Shares if Corporation or % of ownership if LLC or Partnership Date of Birth Name of Principal Residence Social Security #: Title No. of Shares if Corporation or % of ownership if LLC or Partnership Date of Birth 9a. TO BE FILLED IN ONLY BY CORPORATION OR LLC/LLP APPLICANTS (1) State under what law applicant was organized: (2) Date of organization: (3) If applicant is a foreign corporation, has a Certificate of Authority been obtained to do business in this state? (3a) If yes, date of Certificate of Authority: (4) Name of principal place of business: YES NO (5) Address of principal place of business Page 2 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY whlsle-rev10232012 Original Amended Date 174 RIGHT TO PREMISES 1. RIGHT TO PREMISES a. By what right does the applicant have possession of the premises? Own Lease Sub-Lease Binding contract to acquire real property Written intent to Lease Other (explain): b. Do the terms of the lease or other arrangement require the applicant to provide any consideration based on a percentage of the receipts of the business? If YES, list the section/page of the lease this information can be found YES NO 2. INTERESTED PARTIES a. Is there currently a license to traffic in alcoholic beverages in effect for the premises for which this application is filed? YES b. Name of current/previous licensee: NO Do Not Know License Serial Number: c. Are there any disciplinary actions pending against the applicant, current licensee, or prior licensee? YES NO Do Not Know Any pending disciplinary action may prevent a determination on this application or result in the disapproval of the application with or without prejudice. d. Does anyone other than the applicant/principals share or will share on a percentage basis or in any way in the receipts, losses or deficiencies of the business to any extent whatsoever? YES NO If YES, state the names and address of such persons, the nature and percent of their share and date acquired. Name Address Nature of interest Date Acquired Name Address Nature of interest Date Acquired Name Address Nature of interest Date Acquired Name Address Nature of interest Date Acquired Page 3 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY whlsle-rev10232012 Original Amended Date 48 LANDLORD IDENTIFICATION INFORMATION 1. Name of Landlord (as appears on lease and deed): Landlord Mailing Address: City: State: Zip Code: Phone Number (include area code): 2. Landlord Principals Name Address Name Address Name Address Name Address 3(a). Are any persons listed on this form currently or previously licensed under the ABC Law? YES NO 3(b). If YES, list the names and license numbers: 4(a). Are any persons listed on this form police officers: YES NO 4(b). If YES, list the names : 5. List number of years real property has been owned by landlord: Page 4 American LegalNet, Inc. www.FormsWorkFlow.com OFFICE USE ONLY whlsle-rev10232012 Original Amended Date 28 LIST OF EXPENSES FOR THIS VENTURE ALL APPLICANTS MUST COMPLETE THIS SECTION Expense Item (Actual or Estimated) 1. Real Property (if purchased within the past year): 2. Purchase/Contract price (submit copy of contract): 3. Renovations/Improvement Costs (ie: furnishings, fixtures, etc.) : 4. Miscellaneous (any other expense related to this venture): 5. TOTAL CASH 6. TOTAL DEFERRED (See Instructions for required verifications) (Total deferred includes loans, mortgages, lines of credit, notes, etc. Attach copies of EACH source of deferred monies) 7. TOTAL INVESTMENT NOTE: The amounts in items 1 through 4 must total the amount reflected in item 7. The amounts in items 5 and 6 must total the amount reflected in item 7. IMPORTANT: Submit any and all records, documents and affidavits including loan agreements that you feel may assist you in explaining the source of monies as per instruction sheet. List lenders and amounts (to be) loaned from which "total deferred" will derive. Do
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