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Application By Organization For Picnic License - Missouri
| Application By Organization For Picnic License Form. This is a Missouri form and can be used in Alcohol And Tobacco Control Statewide . |
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MISSOURI DEPARTMENT OF PUBLIC SAFETY DIVISION OF ALCOHOL AND TOBACCO CONTROL APPLICATION BY ORGANIZATION FOR PICNIC LICENSE TYPE OR USE ONLY BLACK INK TO COMPLETE THIS APPLICATION LEGAL NAME OF ENTITY EMAIL ADDRESS DOING BUSINESS AS PHYSICAL LOCATION ADDRESS OR LOCATION OF ENTITY'S PRINCIPAL OFFICE (STREET ADDRESS) CITY, STATE, ZIP CODE MAILING ADDRESS (IF DIFFERENT FROM ABOVE) BUSINESS TELEPHONE NUMBER MISSOURI RETAIL SALES TAX NUMBER OR EFFECTIVE DATES OF MISSOURI RETAIL SALES TAX EXEMPTION LETTER LEGAL NAME OF CHURCH, SCHOOL, CIVIC, SERVICE, FRATERNAL, VETERAN, POLITICAL, OR CHARITABLE CLUB OR ORGANIZATION LOCATION OF PRINCIPAL OFFICE SPECIFY THE BASIS OF THE ORGANIZATION'S RIGHT TO OCCUPY PREMISES FOR WHICH IT SEEKS A PICNIC LICENSE. (OWN, LEASE, RENTAL AGREEMENT - STATE TERMS OF AGREEMENT). PLEASE COMPLETE THE FOLLOWING INFORMATION FOR THE MANAGING OFFICER OF THE ORGANIZATION LAST NAME FIRST NAME MIDDLE INITIAL DATE OF BIRTH PLACE OF BIRTH SOCIAL SECURITY NUMBER SEX M F HOME PHONE NUMBER E-MAIL ADDRESS CURRENT ADDRESS CITY STATE & ZIP CODE IS MANAGING OFFICER A NATURALIZED CITIZEN? YES NO IF YES, LIST DATE AND COURT WHICH ADMIITED YOU TO CITIZENSHIP. CITY, TOWN OR VILLAGE WHERE THE MANAGING OFFICER PAYS TAXES MANAGING OFFICER IS REGISTERED TO VOTE IN THE FOLLOWING PRECINCT CITY WARD COUNTY MO 829-A0027 (Rev. 11/19/2012) Application by Organization for Picnic License - Page 1 American LegalNet, Inc. www.FormsWorkFlow.com INFORMATION CONCERNING OWNER(S), MANAGING OFFICER, SHAREHOLDER(S), MEMBER(S) YES 1 Has the organization, the managing officer, any officer or director, or any person with a direct or indirect financial interest in the organization ever been charged with or indicted for, received a suspended imposition of sentence for, or been convicted of a violation of any Federal law, law of the State of Missouri or any other state or country, or entered and/or been present in the United States in violation of Federal immigration laws? NO 2 Has the organization, the managing officer, any officer or director, or any person with a direct or indirect financial interest in the organization ever had a license revoked or suspended by the Supervisor of Alcohol and Tobacco Control or by the licensing authority of any other state, county or city? 3 Does the organization, any officer or director, or the managing officer have any direct or indirect financial interest in any brewery, winery, distillery, rectifying or blending plant, or gasohol facility, or wholesale liquor or beer concern, either as part owner, shareholder, agent, employee or otherwise? 4 Will any distiller, wholesaler, winemaker or brewer, or any employee, officer, or agent thereof, directly or indirectly, loan, give away, or furnish equipment, money, credit, or property of any kind to the organization, except ordinary commercial credit for liquor sold to the organization and accept such articles and services, if any, as are permitted by Section 311.070, RSMo, or the Rules and Regulations of the Supervisor of Alcohol and Tobacco Control, or any who has done so? 5 Is this application made by the organization as a subterfuge to permit any person or entity other than the organization to secure a license from the Supervisor of Alcohol and Tobacco Control, in the organization's name, for his/it's benefit? IF YOU ANSWERED "YES" TO ANY QUESTION ABOVE, EXPLAIN THE ANSWER IN DETAIL BELOW BY PLACING THE QUESTION NUMBER NEXT TO THE EXPLANATION. USE ADDITIONAL SHEET(S) IF NECESSARY. QUESTION # EXPLANATION IMPORTANT You are required to report any change of fact contained herein within ten (10) days! The organization understands that false answers are grounds for denial of a license. The organization understands that if any statements or answers made herein are untrue and the license herein applied for is granted, such license may be revoked, suspended, fined, placed on probation or otherwise disciplined by the Supervisor. The organization acknowledges that any license granted by the Supervisor will be subject to the provisions of Chapter 311, RSMo, and the Rules and Regulations of the Supervisor of Alcohol and Tobacco Control, and that failure to conform thereto will subject its license to suspension, revocation, fine, probation or other discipline by the Supervisor. Further, the organization agrees to allow inspections made in accordance with the Rules and Regulations of the Supervisor of Alcohol and Tobacco Control, and authorizes the Supervisor of Alcohol and Tobacco Control or his duly appointed Agents to examine and secure copies of any and all business records or documents related in any way to this business, including, but not limited to, those on file with any bookkeeper. The organization authorizes the Supervisor of Alcohol and Tobacco Control or his duly appointed Agents to examine and secure copies of any and all financial records, including without limitation, signature cards, checking and savings account statements, notes and loan documents, deposit and withdrawal records, and escrow documents of it's financial institution(s), and any financial documents related to the business. The organization authorizes the Supervisor of Alcohol and Tobacco Control or his duly appointed Agents to conduct a criminal record check of the managing officer and of all the organization's officers and directors. I, (TYPE OR PRINT NAME) , of lawful age, being first duly sworn upon my oath, depose and say that I have read this application and fully understand same and that I know the contents thereof and the answers and statements contained therein and that the same are true. SIGNATURE OF MANAGING OFFICER DATE FOR OFFICE USE ONLY - DO NOT WRITE IN AREA BELOW Based on the information contained herein, the undersigned forward this application for consideration by the Supervisor of Alcohol and Tobacco Control and hereby recommend that this application be approved and the license issued. AGENT DISTRICT SUPERVISOR STATE SUPERVISOR Application by Organization for Picnic License - Page 2 American LegalNet, Inc. www.FormsWorkFlow.com MISSOURI DEPARTMENT OF PUBLIC SAFETY DIVISION OF ALCOHOL AND TOBACCO CONTROL RETAIL LIQUOR BY DRINK (PICNIC) 7 DAYS 1. Completed picnic application form filled out in BLACK INK or TYPED, and SIGNED by Managing Officer. 2. Cashier's check or Money Order payable to the MISSOURI DIRECTOR OF REVENUE in the amount of $25. A business check or cash will not be accepted. 3. Copy of Missouri Retail Sales Tax license in the c
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