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Application For Correction To License Or Permit PLCB-959 - Pennsylvania
| Application For Correction To License Or Permit Form. This is a Pennsylvania form and can be used in Liquor Control Board Statewide . |
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PLCB-959 7/04 I COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD PENNSYLVANIA APPLICATION FOR CORRECTION TO LICENSE OR PERMIT (SEE INSTRUCTIONS ON REVERSE) BUREAU OF LICENSING The undersigned requests a corrected license or permit be issued in accordance with the information shown in Questions 5-8, subject to, and in compliance with the provisions of the Liquor Code and Regulations of the Board, including those provisions pertaining to the licensee being the only person having a pecuniary interest in the licensed business. This application is made for the License term expiring __________________ , _______ . INFORMATION AS IT APPEARS ON PRESENT LICENSE OR PERMIT 1. NAME LICENSE OR PERMIT NO. EXTENDED HOURS FOOD LICENSE YES 2. TRADE NAME (IF ANY) (STREET, RURAL ROUTE, P.O. BOX NO.) (POST OFFICE) NO NO (ZIP) AMUSEMENT PERMIT SUNDAY SALES PERMIT YES 3. ADDRESS OF PREMISES NO (STATE) YES 4. NAME OF MUNICIPALITY TYPE OF MUNICIPALITY CITY 5. NAME OF LICENSEE OR PERMITTEE BORO TWP. INC. TOWN COUNTY INFORMATION AS IT IS TO APPEAR ON CORRECTED LICENSE OR PERMIT 6. TRADE NAME (IF ANY) 7. ADDRESS OF PREMISES (STREET, RURAL ROUTE, P.O. BOX NO.) (POST OFFICE) (STATE) (ZIP) 8. NAME OF MUNICIPALITY TYPE OF MUNICIPALITY CITY 19. BORO TWP. INC. TOWN COUNTY RESOLUTION (CORPORATIONS AND CLUBS ONLY) At a regular or special meeting held on ______________________________________________________ , _________ by the applicant corporation/club, it was resolved that said application be filed with the Pennsylvania Liquor Control Board, and that ________________________________________________ and/or _______________________________________________ is/are (NAME OF OFFICER/TITLE) (NAME OF OFFICER/TITLE) hereby authorized to execute said application, and any other papers required by the Board. I swear or affirm, subject to the penalties provided by 18 Pa. C.S. §4904 and 47 P.S. §4-403(h) and/or §4-436(j) and/or §5-504(b) and/or §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 ) ( ) DO NOT WRITE BELOW THIS LINE American LegalNet, Inc. www.USCourtForms.com INSTRUCTIONS This form is to be used by all licensees and permittees, when there is a change to the name, trade name, or address of the licensed establishment, provided there is no change in the ownership of the business or actual principal location of the licensed premises. The change to licensee name could be a deletion of a partner, either by voluntary retirement or death. If a partner is being added or the ownership is to be changed, or the principal location of the premises is to be changed, an application packet for transfer of license must be submitted. 1. A fee of $45.00 MUST accompany this application, unless the change is ONLY to the mailing address of the licensed premises. 2. The application MUST be signed by all partners appearing on the license as shown on Question 1. Complete information must appear on the form. In the case of death of a partner the application must be signed for the deceased partner by the Administrator or Executor of the estate. A short form certificate from the Registrar of Wills MUST accompany this application. An exception is granted only in cases where the license is issued in the name of husband and wife. If letters of administration are not deemed necessary, the application may be signed only by the surviving spouse; however, documentary evidence of death must then be submitted. In the case of a change to the mailing address, submit a copy of the Post Office's notice of change unless you were notified by the Pennsylvania Liquor Control Board to submit the application. The address reported must be of the licensed premises. It may not be a forwarding address. IF YOU REQUIRE ASSISTANCE IN COMPLETING THE APPLICATION PACKET, CALL THE LICENSING INFORMATION CENTER AT (717) 783-8250. SEND THE APPLICATION PACKET TO: PENNSYLVANIA LIQUOR CONTROL BOARD, BUREAU OF LICENSING, P.O. BOX 8940, HARRISBURG, PA 17105-8940. American LegalNet, Inc. www.USCourtForms.com
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