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Application For Agents License LIQ 365 - Washington
| Application For Agents License Form. This is a Washington form and can be used in Applications Liquor Control Board Statewide . |
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For Office Use Only Licensing and Regulation PO Box 43098 Olympia WA 98504-3098 Phone: (360) 664-1600 Fax: (360) 664-4054 www.liq.wa.gov Date: Check No. Amount Rec'd Rec'd By Application for Agent's License $25 Fee Agent's Licenses Expire June 30th To Be Completed by Applicant Company Full Legal Name of Company or Corporation Represented by Agent Address (City, State, Zip Code) E-mail address License No. of Company Telephone No. To Be Completed by Agent Agent's Name (First, Middle, Last) Please print Agent's Business Address (if different from applicant company) Date of Birth Telephone No. ( ) Do you hold any other job or engage in any other employment with or without pay? If yes, please explain: yes no Do you have any financial interest of any nature whatsoever in any business involved in the retail sale of beer, wine, or spirituous liquor (including lessor or landlord interests in building; or being a holder of a note, mortgage contract, or other forms of obligations or credit arrangements)? yes no If yes, please explain. To Be Completed by Applicant Company and Agent In making this application we agree, if application is approved, to abide by the provisions of the Washington State liquor laws and regulations, with particular reference to RCW 66.24.310, WAC 314-44-005, and WAC 314-12-140. We understand a misrepresentation of fact shall be deemed a lack of good faith and shall constitute good and sufficient cause for disapproval, revocation, or suspension of the license. Agent's Signature Company Authorized Signature Date Date If you have any questions or need assistance, please call (360) 664-1600 Select option 2 LIQ 365 8/11 American LegalNet, Inc. www.FormsWorkFlow.com
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