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Request For Application For License (Liquor-Wine Representative) - New Hampshire

Request For Application For License (Liquor-Wine Representative) Form. This is a New Hampshire form and can be used in Liquor Commission Statewide .
 Fillable pdf Last Modified 3/22/2011
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Liquor Commission Division of Enforcement & Licensing P.O. Box 1795, 10 Commercial Street Concord, NH 03302-1795 Phone: (603) 271-3521 REQUEST FOR APPLICATION TYPE OF APPLICATION LIQUOR WINE REPRESTATIVE Liquor Commission Use Only Control No. District (Lic Spec) Territory # Date Reviewed SPI Date NON REFUNDABLE PROCESSING FEE TO BE MAILED WITH THIS REQUEST: $100 APPLICATION FEE $25 FOR LW REP ONLY NO APPLICATION FEE FOR RETAIL TOACCO ONLY Initials CORP/LLC/LLP NAME APPLICANT NAME LAST HOME ADDRESS NO CITY TRADE NAME LOCATION FOR LICENSE NO CITY MAILING ADDRESS NO CITY BUSINESS PHONE E-MAIL ADDRESS IS THIS A SINGLE PROP PARTNERSHIP/LLP DATE FORMED MM/DD/YY FIRST STREET STATE DATE OF BIRTH ZIP STREET COUNTY STREET STATE HOME PHONE ZIP STATE ZIP CORPORATION LLC IF NON-NH, WHAT STATE CHARTERED IN: APPLICANT OWNS LEASES RENTS PREMISES YES NO HAS APPLICANT PREVIOUSLY OWNED/HAD INTEREST IN ANY LIQUOR LICENSE IF YES, WHEN GIVE LICENSE NO. AND NAME I UNDERSTAND THE REQUIREMENT OF TRAINING WITHIN 45 DAYS OF LICENSING. INCOMPLETE APPLICATIONS MAY DELAY LICENSING. AN ACCURATE MAILING ADDRESS WILL ENSURE YOU RECEIVE CRITICAL CORRESPONDENCE AND RENEWAL APPLICATIONS IN A TIMELY MANNER. I FURTHER UNDERSTAND THAT IF I FAIL TO COMPLY WITH THE TRAINING REQUIREMENT, MY LIQUOR LICENSE WILL BE SUSPENDED 45 DAYS AFTER ITS ISSUANCE AND REMAIN SUSPENDED UNTIL SUCH TIME AS I MEET THE TRAINING REQUIREMENTS. PLEASE CALL (603)271-8531 FOR FURTHER DETAILS OR VISIT US ON THE WEB @ www.nh.gov/liquor Signature Date of Request: L-001 (Reviewed 8/31/10) Lic Specialist Signature Date American LegalNet, Inc. www.FormsWorkFlow.com Last Name First Name Mr. / Ms. Maiden Name Title (Pres., Mbr., etc.) Address State Male Zip Female Home Phone Race D.O.B. Social Security # /Alien Reg. # P.O.B. Drivers License # Height Weight Eye Hair Mother's Last Name Mother's First Name Maiden Name Father's Last Name Father's First Name Last Name First Name Mr. / Ms. Maiden Name Title (Pres., Mbr., etc.) Address State Male Zip Female Home Phone Race D.O.B. Social Security # /Alien Reg. # P.O.B. Drivers License # Height Weight Eye Hair Mother's Last Name Mother's First Name Maiden Name Father's Last Name Father's First Name Last Name First Name Mr. / Ms. Maiden Name Title (Pres., Mbr., etc.) Address State Male Zip Female Home Phone Race D.O.B. Social Security # /Alien Reg. # P.O.B. Drivers License # Height Weight Eye Hair Mother's Last Name Mother's First Name Maiden Name Father's Last Name L-001 a Father's First Name American LegalNet, Inc. www.FormsWorkFlow.com
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