Non Profit Entity Disclosure Form {DLC 4029}

FOR OFFICE USE ONLY NEW PERMIT # TRANSFER REN OHIO DEPARTMENT OF COMMERCE DIVISION OF LIQUOR CONTROL Telephone: (614) 644-2360 - http://www.com.gov/liqr (This form should be used by all non profit businesses, municipal corporations and educational institutions organized not for profit.) DBA Name City, State Tax Identification No. (TIN) Zip Code 6606 Tussing Road, P.O. Box 4005, Reynoldsburg, Ohio 43068-9005 NON PROFIT ENTITY DISCLOSURE FORM Section A Name of Non Profit Entity Permit Premises Address Township, if in Unincorporated Area Email Address: Please be advised that any social security numbers provided to the Division of Liquor Control in this application may be released to the Ohio Department of Public Safety, the Ohio Department of Taxation, the Ohio Attorney General, or to any other state or local law enforcement agency if the agency requests the social security number to conduct an investigation, implement an enforcement action, or collect taxes. SECTION B. If the non profit entity has officers, indicate the top five individuals. If there are no officers, please indicate by writing NONE. These officers are not required to have a background check. NAME OF OFFICER SOCIAL SECURITY NUMBER BIRTHDATE 1) CEO 2) President 3) Vice-President 4) Secretary 5) Treasurer SECTION C. Indicate the officer or individual who is responsible for overseeing the food and beverage service operations of the business/organization. THE INDIVIDUAL LISTED BELOW MUST HAVE A BACKGROUND CHECK PERFORMED BY BCI&I AND SUBMIT A PERSONAL HISTORY BACKGROUND FORM. PLEASE READ "BACKGROUND CHECK INFORMATION" DLC4191. Name Residence Address City and State Telephone No. Zip Code Date of Birth Social Security No. (if individual) State of Ohio, County, ss I, ____________________________________________________being first duly sworn, according to law, deposes and says that he/she is (Title) _____________________ of the __________________________________________________________________, a business duly authorized by law to do business in the State of Ohio, and that the statements made in the foregoing affidavit are true. (Signature) ___________________________________________________ (Print Name and Title) _______________________________________________________ Sworn to and subscribed in my presence this __________________ day of _____________________________________________________, _______________________ ___________________________________________________________ (Notary Public) (Notary Expiration) DLC 4029 EOE/ADA SERVICE PROVIDER FOR TTY USERS DIAL 1-800-750-0750 REV. 08/2015 American LegalNet, Inc. www.FormsWorkFlow.com