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Change In Corporate Officers And Or Stock Ownership BLS-700-306 - Washington
| Change In Corporate Officers And Or Stock Ownership Form. This is a Washington form and can be used in Corporate Information Liquor Control Board Statewide . |
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State of Washington Business Licensing Service PO Box 9034 Olympia WA 98507-9034 1-800-451-7985 bls.dor.wa.gov UBI number Liquor/Lottery license number Office use only For validation only Change In Corporate Officers and/or Stock Ownership 03N-400-925-0003 List fee next to each license you hold and enter total fees due in the box to the right Liquor . . . . . . $75.00 Change in more than 10% of stock or election of new officers. $ Lottery . . . . . $25.00 Change in 10% stock or more (no fee for corporate officer change). $ Gambling . . . $55.00 Change in stock of 10%-50% (no fee for corporate officer change). Contact the Gambling Commission if the change is greater than 50% Make check payable to the Department of Revenue $ Amount due Total amount due $ Corporate officer changes should also be filed with the Washington Secretary of State. Corporate Information Corporate name as registered with the Washington Secretary of State Corporation mailing address (Street or route) Contact name (Last, First, Middle) City State ZIP Code UBI number (Area code) Telephone number Contact (Area code) Telephone number Corporate Officers Name (Last, First, Middle) At the completion of this corporate change, the officers will be: Birth date City State Social Security Number ZIP Code Percent owned President Home address (Street or route) Name of spouse (Last, First, Middle) Name (Last, First, Middle) Home address (Street or route) Name of spouse (Last, First, Middle) Name (Last, First, Middle) (Area code) Telephone number Vice president Birth date City State Social Security Number ZIP Code Percent owned (Area code) Telephone number Birth date City State Social Security Number ZIP Code Percent owned Secretary Home address (Street or route) Name of spouse (Last, First, Middle) Name (Last, First, Middle) (Area code) Telephone number Birth date City State Social Security Number ZIP Code Percent owned Treasurer Home address (Street or route) Name of spouse (Last, First, Middle) (Area code) Telephone number If necessary, attach additional sheets using the same format as shown above. Please continue on to the next page. Your signature is required on page 2. For assistance or to request this document in an alternate format, visit http://business.wa.gov/BLS or call 1-800-451-7985. Teletype (TTY) users may call 360-705-6718. BLS-700-306 (5/17/11) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Stock ownership Total stock authorized Number of shares issued Par value per share List of stockholders and stock certificates Please complete all the following. Start with certificate number 1. If more space is needed, attach additional sheets using the same format. Name of stockholder (Last, First, Middle) Home address (Street or route) Number of shares owned % owned City State ZIP code Social Security number Name of spouse (Last, First, Middle) Birth date Date(s) issued or enter "Pending" if not yet issued Social Security number City State ZIP code Name of spouse (Last, First, Middle) Birth date Name of stockholder (Last, First, Middle) Home address (Street or route) Number of shares owned % owned Date(s) issued or enter "Pending" if not yet issued Social Security number City State ZIP code Name of spouse (Last, First, Middle) Birth date Name of stockholder (Last, First, Middle) Home address (Street or route) Number of shares owned % owned Date(s) issued or enter "Pending" if not yet issued Social Security number City State ZIP code Name of spouse (Last, First, Middle) Birth date Name of stockholder (Last, First, Middle) Home address (Street or route) Number of shares owned % owned Date(s) issued or enter "Pending" if not yet issued Social Security number City State ZIP code Name of spouse (Last, First, Middle) Birth date Name of stockholder (Last, First, Middle) Home address (Street or route) Number of shares owned % owned Date(s) issued or enter "Pending" if not yet issued Social Security number City State ZIP code Name of spouse (Last, First, Middle) Birth date Name of stockholder (Last, First, Middle) Home address (Street or route) Number of shares owned % owned Date(s) issued or enter "Pending" if not yet issued Additional forms or documents may be required by the individual agency. Liquor Control Board (360) 664-1600 · Lottery (360) 753-2155 · Gambling (360) 438-7654 ext. 300 Certification Under penalty of perjury, I hereby certify there have been no changes in officers or stockholders that have not been reported, and that each officer and stockholder is the real party in interest with respect to his/her position and is not acting directly or indirectly as agent, employee or representative of any other person not reported. I certifiy on behalf of the corporation that it is understood that a misrepresentation of fact is cause for rejection of this application or revocation of any license issued. For gambling only: Elected chief executive must sign below. Print name ______________________________________________________ Title ___________________________ Signature ____________________________________________________________________ Date ______________ BLS-700-306 (5/17/11) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com
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