Affidavit And Application Class II Temporary Permit Affidavit Authorizing Class 2

ABCD 1000T2 (REVISED 08/2013) APPLICATION AND AFFIDAVIT CLASS 2 TEMPORARY RETAILER'S PERMIT ALCOHOLIC BEVERAGE CONTROL PERMIT DEPARTMENT P.O. BOX 540 MADISON, MS 39130-0540 RETURN TO American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS PLEASE READ PRIOR TO COMPLETING THIS FORM 1. An application fee of $75.00, in the form of a cashier's check or money order payable to the Alcoholic Beverage Control must be returned with this completed application. The applicant's signature must be notarized by a licensed Notary Public. The PRESENT OWNER must complete the affidavit authorizing the issuance of a Class II Temporary Permit for the licensed business. If the existing permit is due to expire within the 70 days of issue of a Class 2 Temporary Permit, an application for renewal of that permit must be submitted along with this form. Submit either an original application for a Sales Tax number or a copy of the sales tax application stamped received and dated by the Department of Revenue along with this form. (NOTE: A CLASS 2 TEMPORARY PERMIT WILL NOT BE ISSUED 2. 3. 4. 5. WITHOUT PROOF OF APPLICATION FOR A SALES TAX NUMBER BY THE PROSPECTIVE NEW OWNER, AND NO PERMIT WILL BE ISSUED IF THE PRESENT OWNER IS INDEBTED TO THE STATE OF MISSISSIPPI FOR ANY TAXES, FEES, OR PENALTIES. THE PRESENT OWNER'S SALES TAX ACCOUNT MUST REMAIN OPEN AND ACTIVE DURING THE 70-DAY CLASS 2 PERIOD.) 6. After this temporary permit is issued, applicants have fourteen (14) days to submit a completed application for transfer. Failure to submit a completed transfer application within 14 days, or failure to comply with instructions will result in the Class 2 permit being voided. This permit expires seventy (70) days after issuance. Holders of Temporary Class 2 permits must order all alcoholic beverages from the ABC. Purchases from wholesale package retailers are prohibited while operating under a Class 2 permit. (MS Code Annotated Section 67-151, subsection f) 7. ALL CLASS 2 TEMPORARY PERMIT HOLDERS MUST DO BUSINESS WITH THE ABC USING CERTIFIED FUNDS. ORDERS FOR ALCOHOLIC BEVERAGES MUST BE PAID WITH A MONEY ORDER OR A CERTIFIED CHECK FOR THE AMOUNT OF PURCHASE AND ANY FEES DUE. NEITHER PERSONAL CHECKS NOR COMPANY CHECKS ARE ACCEPTABLE. CASH IS ACCEPTED ONLY IF DELIVERED IN PERSON. BRING EXACT AMOUNT DUE. CHANGE IS NOT AVAILABLE. If you have questions concerning this application, contact the Permit Dept. at 601-856-1330. American LegalNet, Inc. www.FormsWorkFlow.com (08/2013) PERMIT DEPT. USE ONLY AMT. OF CHECK CHECK NUMBER PERMIT NUMBER AFFIDAVIT and APPLICATION, CLASS II TEMPORARY PERMIT AFFIDAVIT AUTHORIZING CLASS 2 , doing business as ,ABC Permit No. hereby authorize the Alcoholic Beverage Control to issue a Class 2 Temporary Retailer's Permit to doing business as effective . (current permit holder's signature) I, APPLICATION FOR CLASS 2 TEMPORARY PERMIT I. APPLICANT: MAILING ADDRESS: II. BUSINESS: (name of sole owner, partnership, llc, or corporation) (street/p.o. box) (city) (tradename) (street) (city) (zip) (state) (zip) LOCATION ADDRESS: COUNTY: III. IV. TELEPHONE No. (b.) (h.) TYPE OF APPLICANT ENTITY: ( ) Sole Owner ( ) Partnership ( ) Corporation ( ) Trust ( ) LLC ( ) Other Have you or any member of your partnership, LLC, or association, or any officer, director, or majority stockholder of your corporation, ever been convicted or any of the following: a felony regardless of its nature in any state or federal court; a violation of the Local Option Alcoholic Beverage Control Laws; or, violation of any other law relating to alcoholic beverages, beer or light wine? If "yes", explain fully: American LegalNet, Inc. www.FormsWorkFlow.com PERMITTEE CERTIFICATION AND OATH I, , certify under penalty of perjury that the organization applying for this Temporary Class 2 Permit does meet the qualifications of Sections 67-1-51(l), (m), (n), (o), (p), or (q), 67-1-37, 67-1-51, (2) and (3), 67-1-55, 67-1-57 and 67-1-59. I affirm that this organization, in the exercise of this permit, will comply with the Local Option Alcoholic Beverage Control Laws, Rules and Regulations, relative to the purchase, sale and handling of alcoholic beverages and will keep all records and make all reports and remittances as required thereby. I certify that the information presented on the application to be true and correct, to the best of my knowledge and belief. I also agree that making a material misrepresentation on this application shall be evidence of a lack of trustworthiness as contemplated by MS Code Ann. Section 67-1-57 and provide a basis for denial on this application. BY: TITLE: DATE: NOTARY State of County of THIS DAY personally appeared before me, the undersigned authority in and for the county and state aforesaid, the within named with, after being duly sworn states on oath that the matters and things contained and set forth in the foregoing application are true and correct as stated. Sworn to and subscribed before me, this the day of (Notary Public) My commission expires: , American LegalNet, Inc. www.FormsWorkFlow.com