California > Statewide > Department Of Alcoholic Beverage Control
Application Questionnaire ABC-217 - California
| Application Questionnaire Form. This is a California form and can be used in Department Of Alcoholic Beverage Control Statewide . |
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Department of Alcoholic Beverage Control APPLICATION QUESTIONNAIRE Please read instructions, which includes Privacy Notice, before completing form. 1. APPLICANT'S NAME(S) (If an individual, first name, middle name, last name. Name of entity if corporation, limited partnership or limited liability company.) State of California Edmund G. Brown Jr., Governor P-12 LICENSEE Yes 2. LICENSE TYPE(S) (Check appropriate items) 3. TRANSACTION TYPE (Check appropriate item) No (If yes, complete form ABC-811) 20 Off-Sale Beer & Wine 21 Off-Sale General 40 On-Sale Beer 41 On-Sale Beer & Wine Eating Place 42 On-Sale Beer & Wine Public Premises 47 On-Sale General Eating Place 48 On-Sale General Public Premises Other 4. TEMPORARY PERMIT REQUESTED (Person-to-Person transfers only) Original (New) Person-to-Person Transfer (check appropriate section): Section 24071 (Surviving spouse, corporations, fiduciaries, etc.) Section 24071.1 (Corporate Stock/Limited Partnership) Section 24071.2 (Limited Liability Company) Premises-to-Premises Transfer Exchange Other Yes No County 5. PREMISES ADDRESS (Where license to be issued) (Street number and name, city, zip code) 6. PREMISES TELEPHONE NUMBER 7. PREMISES ARE INSIDE CITY LIMITS 8. BUSINESS NAME (DBA) YOU WILL USE ( ) Yes No 10. MAILING ADDRESS 9. BUSINESS MAILING ADDRESS (Street number and name, city, state, zip code) Permanent 11. ABC LICENSE COST (Item #32a on reverse) 12. SUBTOTAL (Item #32f on reverse) Temporary 13. HAS THE APPLICANT(S) EVER BEEN CONVICTED OF A FELONY? 14. HAS THE APPLICANT(S) EVER VIOLATED ANY OF THE PROVISIONS OF THE ALCOHOLIC BEVERAGE CONTROL ACT OR REGULATIONS OF THE DEPARTMENT PERTAINING TO THE ACT? Yes No Yes No 15. IF YES TO ITEM 13 OR 14, PLEASE EXPLAIN 16. TRANSFEROR'S NAME (If an individual, last, first, middle. Name of entity if corporation, limited partnership or limited liability company.) 17. ABC LICENSE NUMBER 18. TRANSFEROR'S PREMISES ADDRESS (Where license is now issued) (Street number and name, city, zip code) 19. PREMISES UNDER CONSTRUCTION IF YES, LIST ESTIMATED COMPLETION DATE 20. FRANCHISE Yes No 22. TITLE OF CONTACT PERSON Yes No 21. NAME OF PERSON WE MAY CONTACT (For the applicant) 23. CONTACT TELEPHONE NUMBER 24. CONTACT E-MAIL ADDRESS ( Yes ) IF YES, TYPE OF LICENSE 26. CURRENT LICENSE IS OPERATING IF NO, DATE CLOSED 25. PREMISES IS CURRENTLY LICENSED No ESCROW COMPANY'S ADDRESS Yes No TELEPHONE NUMBER FINANCIAL INFORMATION 27. ESCROW COMPANY'S NAME ( 28. BOOKKEEPER/ACCOUNTANT'S NAME BOOKKEEPER/ACCOUNTANT'S ADDRESS ) ) ) None TELEPHONE NUMBER ( 29. LANDLORD'S NAME LANDLORD'S ADDRESS TELEPHONE NUMBER ( 30. MONTHLY RENT 31. LEASE EXPIRATION DATE 32. INDICATE WHETHER LEASE OR RENTAL AGREEMENT INCLUDES FURNITURE OR FIXTURES All ABC-217 (rev. 11/11) Some American LegalNet, Inc. www.FormsWorkFlow.com 33. INVESTMENT INFORMATION a. ABC License b. Furniture/fixtures c. Inventory d. Goodwill/non-compete covenant e. Leasehold and/or Improvements f. SUBTOTAL (Usually should equal the recorded notice) g. Fees for other licenses, permits, and deposits (approximate). Include Federal, State, County or City license fees or permits; lease and utility deposits h. Working capital (approximate) i. Realty or interest therein j. TOTAL INVESTMENT (Items f through i) (will equal total of amounts listed in item #33) COST $ $ $ $ $ $ $ $ $ $ 34. Source of Funds for Total Investment (item #32j) - identify amount(s), type(s) and explain source(s) and/or terms of Repayment Amount $1,000 $15,000 $10,000 Type Gift Promissory Note Loan Source and/or Terms of Repayment John Doe, Brother to seller, payable @ $1,000 per month for 15 months from ABC Bank, @ 8.5% over 5 yrs; monthly payment = $2,052 35. LIST ALL BANK ACCOUNTS FOR THIS BUSINESS OPERATION BANK NAME BANK ADDRESS ACCOUNT NUMBER a. b. c. NAMES OF ALL PERSONS AUTHORIZED TO SIGN ON BANK ACCOUNT(S) (Print) I understand that falsification of the information on this form may constitute grounds for denial or revocation of the license(s). For a period of 90 days from this date, I/we hereby authorize the Department of Alcoholic Beverage Control, or any of its officers, to examine and secure copies of financial records consisting of signature cards, checking and savings accounts, notes and loan documents, deposit and withdrawal records, and escrow documents of my/our financial institution(s) or any financial records established in connection with this business. This authorization to examine records at any financial institution may be revoked at any time. I/we also authorize the Department of Alcoholic Beverage Control, or any of its officers, to examine and secure copies of any business records or documents established in connection with this business including, but not limited to those on file with my/our bookkeeper. I/we also read all of the above and declare under penalty of perjury that each and every statement is true and correct. 36. APPLICANT SIGNATURE (Only one signature needed) PRINTED NAME DATE SIGNED ATTEST (ABC Employee or Notary Public) ABC-217 (rev. 11/11) American LegalNet, Inc. www.FormsWorkFlow.com
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