Maine > Statewide > Liquor Licensing And Inspection Division
Agency Renewal Application - Maine
| Agency Renewal Application Form. This is a Maine form and can be used in Liquor Licensing And Inspection Division Statewide . |
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MAINE DEPT OF PUBLIC SAFETY STATE OF MAINE Liquor Licensing & Inspection Division 164 State House Station Augusta ME 04333-0164 Tel: (207) 624-7220 Fax: (207) 287-3424 BUREAU USE ONLY License No. Assigned: Class: Deposit Date: Amount Deposited: AGENCY LIQUOR STORE RENEWAL $300.00 RESELLING AGENT - $50.00 CHECK PAYABLE: TREASURER STATE OF MAINE PRESENT LICENSE EXPIRES ________________ ALL QUESTIONS MUST BE ANSWERED IN FULL 1. APPLICANT(S) (Sole Proprietor, Corporation, Limited Liability Co., 2. Business Name (D/B/A) etc.) DOB: DOB: Location (Street Address) DOB: Address City/Town Mailing Address City/Town Telephone Number Federal I.D. # State FAX: Zip Code City/Town Business Telephone Number Seller Certificate # State FAX: Zip Code State Zip Code 3. Is applicant a Corporation, Limited Liability Company or Limited Partnership? If answer is "yes", complete Supplementary Questionnaire. Yes No 4. Have any changes occurred in Ownership, Partnership or Corporate structure since last renewal? Yes No 5. List current annual dollar sales of: Retail sales: $ ______________ Wholesale/Licensee sales: $ _______________ 6. List current on-hand inventory of spirits, in dollars: $ _______________ 7. Basic Federal Permit # _______________ Town/City, State Federal Tax Stamp EIN # _______________ Tax Year 20 _____ Month/Day Dated at: ______________________________________________ on ____________________ , 20 _____ __________________________________________ ________________________________________________ Signature of Individual(s) or Duly Authorized Officer of Corporation or, if Partnership, by Member NOTE: I understand that false statements made on this form are punishable by law. Knowingly supplying false information on this form is a Class D offense under the Criminal Code, punishable by confinement of up to one year, or by monetary fine of up to $2000, or by both. AgncyRenApp / 2003 American LegalNet, Inc. www.FormsWorkflow.com
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