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Application For Approval Of Appointment Of Manager PLCB-706 - Pennsylvania
| Application For Approval Of Appointment Of Manager Form. This is a Pennsylvania form and can be used in Liquor Control Board Statewide . |
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PLCB-706 2/03 I COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD APPLICATION FOR APPROVAL OF APPOINTMENT OF MANAGER (SEE INSTRUCTIONS ON REVERSE) BUREAU OF LICENSING 5A LID NO. Approval is requested for the appointment of a 1. NAME 2. TRADE NAME (IF ANY) 3. ADDRESS OF PREMISES PERMANENT TEMPORARY Manager for the following licensee: LICENSE NO. (STREET, RURAL ROUTE, P.O. BOX NO.) (POST OFFICE) (STATE) (ZIP) 4. DO YOU HOLD ANY OTHER LICENSE ISSUED BY THIS BOARD? IF "YES," GIVE LICENSE NO.(S) YES NO INFORMATION CONCERNING PROPOSED MANAGER: (An individual licensee may designate himself as manager) 5. NAME 6. HOME ADDRESS 7. DATE AND PLACE OF BIRTH 8. STATE PRESENT EMPLOYMENT OR OTHER BUSINESS 9. ARE YOU OR HAVE YOU EVER BEEN EMPLOYED BY ANOTHER LICENSEE? IF "YES", WHEN AND IN WHAT CAPACITY? (STREET, RURAL ROUTE, P.O. BOX NO.) (POST OFFICE) (STATE) (ZIP) U.S. CITIZEN? IF NATURALIZED, GIVE DATE AND PLACE YES NO ARE YOU OR HAVE YOU EVER BEEN A LICENSEE? YES YES NO NO 10. CONVICTION RECORD: The following is a record of all felony and misdemeanor convictions of the proposed manager. (Attach separate sheet, if necessary.) If there have been no such convictions, check NAME DATE OF CONVICTION CHARGE No Such Convictions. DISPOSITION LOCATION OF COURT (COUNTY AND STATE) FOR TEMPORARY MANAGER ONLY 11. APPOINTMENT DATE REASON FOR APPOINTMENT FROM TO RESOLUTION (CORPORATIONS ONLY) 12. At a regular or special meeting held on _________________________________________ , 20 _______ by the applicant corporation, it was resolved that said application be filed with the Pennsylvania Liquor Control Board, and that ___________________________________________ and/or __________________________________________ is/are hereby (NAME OF OFFICER/TITLE) (NAME OF OFFICER/TITLE) authorized to execute said application, and any other papers required by the Board. DO NOT WRITE BELOW THIS LINE American LegalNet, Inc. www.USCourtForms.com 13. FOR LIMITED WINERY APPLICANTS ONLY Is the appointment of manager for an additional Board-Approved Location? If "Yes," list the location: YES NO If "Yes," is/are other licensed limited winery(ies) operated in conjunction with the above listed Board-Approved location? If "Yes," will the proposed manager act as manager for each limited winery(ies)? If "Yes," list license number(s), LID(s) and licensee(s) name: YES NO YES NO 14. Is the proposed manager: YES NO YES NO A B C Officer, director, stockholder or creditor of any other licensee? Owner, proprietor or lessor of any place licensed by this Board? Financially interested, either directly or indirectly, in the profits of any business licensed by this Board? D E F G Public official enforcing penal laws, either by appointment or election? Employee of any licensee? Holder of any license issued by this Board? Employee of the Pennsylvania Liquor Control Board? If "Yes," explain: I swear or affirm, subject to the penalties provided by 18 Pa. C.S. §4904 47 P.S. §4-403(h) and/or §4-436(j) and/or §5-504(b) and/or §7-7-704, that the foregoing answers and statements provided herein are true and complete to the best of my knowledge and belief. SIGNATURE TITLE NAME OF ATTORNEY REPRESENTING YOU IN THIS MATTER, IF ANY HOME ADDRESS PHONE ADDRESS ( SIGNATURE TITLE ) PHONE ( HOME ADDRESS PHONE DATE SIGNED ) ( ) INSTRUCTIONS This form is for the appointment of a permanent manager, for a change of the permanent manager, or for the temporary appointment of a manager. Corporations, except clubs, should use this form to report a change in manager only. If there have been other officer changes in addition to the change of the manager, complete Form PLCB-866, Notice of Change in the Officers, Directors, Stockholders or Manager of Licensed Corporations, Except Clubs to report those changes. 1. A fee of $60.00 MUST accompany this form. A fee submitted from out-of-state must be in the form of a certified check or money order. If an investigation is required an additional $75.00 will be required. 2. One photograph of the manager, 1½" x 1½" in size, taken within one year and the name of the person, license number and the name and address of the premise must appear on the reverse of each photograph, MUST accompany this form. The photograph must have a matte finish. 3. A Request for Criminal Record Check, Form PLCB-2018, MUST be submitted for the proposed manager with a $10.00 remittance. 4. PLCB-1773, Appendix Social Security Information MUST be submitted listing the social security number of the proposed manager. IF YOU REQUIRE ASSISTANCE IN COMPLETING THE APPLICATION PACKET, CALL THE LICENSING INFORMATION CENTER AT (717) 783-8250. American LegalNet, Inc. www.USCourtForms.com
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