interim license application checklist - oklahoma form-interim retail... · can be provided prior to...

ALCOHOLIC BEVERAGE LAWSENFORCEMENT COMMISSION

3812 N. Santa Fe, Suite 200Oklahoma City, OK 73118

(405) 521-3484

INTERIM LICENSE APPLICATION CHECKLISTBefore completing the application packet read the information below:

•Thebuildinglocationmustbecompletelyconstructedorwithin60daysofcompletionofconstruction inordertoapplyforalicense.

•Both the application pages and additional items required must all be completed and provided forfilingortheapplicationwillnotbeaccepted(onlyexception;thecertificateofcompliance can be provided prior to license issuance).

•Theapplicationwillbereviewedandunderinvestigationuponfilingofapplication.

•The license fee is due upon filing the application.We accept cash, credit card, business check, moneyorder,orcashier’scheckforwalk-incustomers.Mail-incustomerscansubmitthelicensefee bymoneyorder,cashier’scheck,orbusinesscheckonly.

•File the completed application in personor bymail at theABLECommission, 3812N.SantaFe Avenue,Suite200,OklahomaCity,OK73118,MondaythruFriday7:30amto4:30pm.

•ContacttheABLECommissionofficeat(405)521-3484orvisitourwebsiteatwww.able.ok.govfor questionsorgeneralinformation.

Additional items an individual sole proprietor must provide:•ACertificateofLiabilityInsuranceshowingcoverageforbothbodilyinjuryandpropertydamage.

•Adeed,lease,managementagreement,orsalescontractintheindividual’sname.

•ACertificateofCompliancefromthecityorcountywherethebusinessislocatedstatingallbuilding codesforzoning,fire,safety,andhealthareincomplianceorarenotrequired.

•ATaxStatement fromtheCountyTreasurer’sofficestatingnorealorpersonalproperty taxesare owedfortheindividual.

ADDITIONAL ITEMS FOR CORPORATIONS, LIMITED LIABILITY COMPANIES, PARTNERSHIPS AND TRIBES OR TRIBAL CORPORATIONS ARE LISTED UNDER THEIR

RESPECTIVE SECTIONS IN THE FOLLOWING APPLICATION.

ABLE Form #ILA-1 Revised 02/18

ALCOHOLIC BEVERAGE LAWSENFORCEMENT COMMISSION

3812 N. Santa Fe, Suite 200Oklahoma City, OK 73118

(405) 521-3484

INTERIM LICENSE APPLICATIONPleasecompletetheentireform.NolicenseswillbeissuedunlesstheABLECommissionisabletoverifytheinformationprovided.TheABLECommissionmayrequestadditionalinformationnotrequestedonthisapplication.Additionalinformationmayberequiredpriortotheissuanceofanylicense.

INTERIM LICENSES AND FEES

BUSINESS OWNERSHIP INFORMATION

c Wine&SpiritsWholesaler-$5500.00 c BeerDistributor-$1750.00 c RetailBeer-$750.00 c RetailWine-$1250.00

1.PrimaryBusinessatthisLocation

c GroceryStore c Pharmacy c Other

c ConvenienceStore c WholesalerofWine&Spirits c BeerDistributor

2. DBA Name of Location

3. Location Address

4. Mailing Address

City

5. Business Phone Number 6. Alternate Phone Number 7. E-mail Address

City

County

County

State

State

Zip

Zip

8. TypeofOwner

c Individual c Partnership c LimitedPartnership c GeneralPartnership c Corporation

c LimitedLiabilityCompany c Tribe c TribalCorporation/Entity c Other__________________________

9a. NameofIndividual/SoleProprietor(ifownedbyanindividual) 9b. SocialSecurityNumber

10b.FederalEmployerIdentification#10a.NameofBusinessEntity(ifPartnership,Corp.,LLCorTribe)


BUSINESS OWNERSHIP INFORMATION

14a.Wheredidyourfundingforthisbusinessoriginate?Check and list all that apply.

I,_________________________________,beingdulyswornuponoathdeposesandsays:Thathe/sheistheapplicantwhomakestheaboveandforegoingapplication,thathe/shehasreadandsignedthesame;knowsthecontentsthereofandthatallstatementsthereincontainedaretrue.Applicant(s)certifiesthatthestatementsandrepresentationsmadehereinaretrueandcorrectandconsentsthatifanystatementsandrepresentationshereinarefoundtobefalseoromitted,thattheDirectormayrefusetoissuesaidlicenseormaycausesuchlicensetoberevokedforthwithatanytime.He/Shefurtheragreesthathe/shehasfiledallappropriatepropertywiththeCountyAssessorandthatalladvaloremtaxesassessedonhis/herproperty,bothrealandpersonal,andwhereversituated in thestateofOklahoma,havebeenpaid.

_________________________________________________ SignatureofApplicant(s)

INVESTMENT TYPE AMOUNT INVESTMENT TYPE AMOUNT

c OngoingBusinessFunds $ c Cash/PersonalFunds $

c PromissoryNote $ c Services $

c Loan $ c Equipment $

c Gift $ c OperatingCapital $

c Other $

12. Application Contact Person

Application Contact Address

Application Contact Phone Number Application Contact E-Mail Address

13. Name of General Manager Onsite General Manager Phone Number

11.WasPremisesPreviouslyLicensedbytheCommission

c Yes c No

IfYes,toWhom? TypeofLicense

14b.Whomorwheredidtheinitialinvestmentcomefrom?ex. Bank, family owned operation, line of credit, investment type, etc.


CORPORATION

CORPORATE OWNERSHIP INFORMATION

Corporationsmustcompletethissectionandprovidethefollowingitems:

•ACertificateofGoodStandingfromtheOklahomaSecretaryofState.Contact(405)521-4211

•ACertificateofIncorporationfromtheSecretaryofState.

•AcopyofMinutesElectingCorporateOfficers,Directors,Stockholders,andapplyingfora license withABLE.

•ACertificateofLiabilityInsuranceshowingcoverageforbothbodilyinjuryandpropertydamage.

•Adeed,lease,managementagreement,orsalescontractinthenameoftheCorporation.

•ACertificateofCompliancefromthecityorcountywherethebusinessislocatedstatingallbuilding codesforzoning,fire,safety,andhealthareincomplianceornotrequired.

•ATaxStatement fromtheCountyTreasurer’sofficestatingnorealorpersonalproperty taxesare owedfortheCorporation.

•OnlyStockholdersowning15%ormorearerequiredtobereportedforCorporations.

SSNorFEI#

SSNorFEI#

SSNorFEI#

Drivers License No./State



Birthdate(mm/dd/yyyy)



No. of Shares

No. of Shares

No. of Shares

c Officer c Directorc Stockholder c Trustee/Beneficiary



Title

Title

Title

Last NameFirstNameorEntityName MI



1.FederalEmployerIdentificationNumber

2.BusinessEntityName

3. No. of Shares Authorized to Issue No. of Shares Issued No. of Shares Unissued

4. Service Agent Service Agent Address


CORPORATE OWNERSHIP INFORMATION (continued)

SSNorFEI#

SSNorFEI#

SSNorFEI#

SSNorFEI#

SSNorFEI#

SSNorFEI#

SSNorFEI#















No. of Shares

No. of Shares

No. of Shares

No. of Shares

No. of Shares

No. of Shares

No. of Shares








Title

Title

Title

Title

Title

Title

Title








IF YOU NEED MORE SPACE USE ADDITIONAL COPIES OF THIS PAGE


LIMITED LIABILITY COMPANY

LIMITED LIABILITY COMPANY OWNERSHIP INFORMATION



SSNorFEI#

SSNorFEI#

SSNorFEI#







% Membership or Units



c Managerc Member

c Managerc Member

c Managerc Member

Title

Title

Title




3. No. of Memberships or Units Issued 4. Member Managed or Manager Managed

c MemberManaged c ManagerManaged

5. Resident Agent Name

Resident Agent Address

LimitedLiabilityCompaniesmustcompletethissectionandprovidethefollowingitems:

•ACertificateofGoodStandingfromtheOklahomaSecretaryofState.Contact(405)521-4211

•AcopyoftheArticlesofOrganizationfiledwiththeSecretaryofState.

•A copy of LLCOperatingAgreement including the schedule or attachment showingmembership interest.


•Adeed,lease,managementagreement,orsalescontractinthenameoftheLLC.


•ATaxStatement fromtheCountyTreasurer’sofficestatingnorealorpersonalproperty taxesare owedfortheLLC.


LIMITED LIABILITY COMPANY OWNERSHIP INFORMATION (continued)


SSNorFEI#

SSNorFEI#

SSNorFEI#

SSNorFEI#

SSNorFEI#

SSNorFEI#

SSNorFEI#






















c Managerc Member

c Managerc Member

c Managerc Member

c Managerc Member

c Managerc Member

c Managerc Member

c Managerc Member

Title

Title

Title

Title

Title

Title

Title









PARTNERSHIP INFORMATION

PARTNERSHIP




SSNorFEIN#

SSNorFEI#

SSNorFEI#

SSNorFEI#









% of Interest

% of Interest

% of Interest

% of Interest

c GeneralPartnerc LimitedPartner




Title

Title

Title

Title





Partnerships, Limited Partnerships or General Partnerships must complete this section and providethefollowingitems:

•ACertificateofPartnershipfromtheOklahomaSecretaryofState.Contact(405)521-4211

•AcopyofthePartnershipAgreementlistingallpartnersandtheamountofinteresteachpartnerowns.


•Adeed,lease,managementagreement,orsalescontractinthenameofthePartnership.


•ATaxStatement fromtheCountyTreasurer’sofficestatingnorealorpersonalproperty taxesare owedforeachpartner.


PARTNERSHIP INFORMATION (continued)

SSNorFEI#

SSNorFEI#

SSNorFEI#

SSNorFEI#

SSNorFEI#

SSNorFEIN#

SSNorFEI#















% of Interest

% of Interest

% of Interest

% of Interest

% of Interest

% of Interest

% of Interest








Title

Title

Title

Title

Title

Title

Title










TRIBE/TRIBAL OWNERSHIP INFORMATION

TRIBE/TRIBAL CORPORATION


2.NameofTribeorTribalEntity


SSNorFEI# Drivers License No./State Birthdate(mm/dd/yyyy)

c TribalCommitteeOfficer

TitleLast NameFirstNameorEntityName MI










Tribes or Tribal Corporations must complete this sectionandprovidethefollowingitems:

•YoumustsubmitacopyofanyexecutedManagementAgreements.

•YoumustsubmitacopyofthetrustdocumentordeedforthepropertyfortheTribeorCorportation.

•Youmustsubmitaletterfromthetribestatingwhetherofnottheyrequirebuildingcodeinspections orstatingthelocationmeetszoning,fire,safety,andhealthcodes.

•Youmustsubmitaletterfromthetribestatingallrealandpersonalpropertytaxeshavebeenpaidor theirtaxstatusistax-exempt.

•YoumustsubmitaletterfromtheIntertribalCommissionapprovingthetribalgamingcompact.

•YoumustsubmitacopyofasignedandcompletedTribalGamingCompact.

•Youmust submit a copy of the tribal rules, regulations, laws, or ordinances related to alcoholic beverages.


TRIBE/TRIBAL OWNERSHIP INFORMATION (continued)
























RESIDENTIAL ADDRESS

RESIDENT STATUS

APPLICANT

5.SocialSecurityNumber 6. Drivers License No. / State 7.PlaceofBirth(City,State,Country)

8.Sex 9. Height 10. Weight 12.EyeColor11. Hair Color

13. Home Phone 14. Business Phone

15. Email Address

16.Listresidentialaddressesforthepast(5)yearsstartingwiththecurrentaddress.Attachaseparatesheet ifnecessary.

17a.AreyouaU.S.Citizen?

c Yes c No

17c.If“Naturalized”providethe“A”number? 17d.If“NO”whatisyourlegalstatusintheU.S.?

17b.If“Yes”,answerthefollowing

c NativeBorn c Naturalized

4.Birthdate(mm/dd/yyyy)3. Last Name1. First Name 2. MI

NUMBER AND STREET CITY, STATE, ZIP FROM(mm/yyyy) TO(mm/yyyy)

INDIVIDUAL PERSONAL HISTORYMUST BE COMPLETED BY ALL APPLICANTS:

Individuals,partners,corporateofficers,directors,stockholders,LLCmanagers,LLCmembers, tribal members, trustees, etc.

•Pleasecompleteallfieldsandanswerallquestions.

•AnyfalsestatementwilldisqualifyyouandsubjectyoutoprosecutionunderOklahomaStatelaw.

CURRENT EMPLOYMENT18a.NameofEmployer

Title

Employer’sAddress

From(mm/yyyy) To(mm/yyyy)

17e.ProvidealldocumentssuchasVisa,ResidentAlienorEmploymentAuthorizationDocuments


INDIVIDUAL QUESTIONNAIRE

19e.Ifyouhaveanswered“Yes”to19athrough19d,listbelow

OFFENSE DATE CITY/COUNTY STATE DISPOSITION(fine,probation,incarceration)

20.Areyoupresentlyorhaveyoubeenlicensedoremployedintheliquorbusiness?

c Yes c No

LICENSE TYPE LICENSE NUMBER WHEN LOCATION

21.Haveyoueverreceivedawarning,anoticeofviolation,suspension,fineorrevocationasalicensee?

c Yes c No

WHEN LOCATION

22.Haveyoueverbeenrefusedalicensetosell,serveordispensealcoholicbeverages?

c Yes c No

WHEN LOCATION

23.Haveyoueverheldordoyouholdanyfinancialinterestinanyliquorenterprise(manufacturing,importing, wholesaleorretail)?

c Yes c NoWHEN LOCATION

19b.Haveyoubeenconvictedofanycrime,violationorinfractionofanylaw?

c Yes c No

19c.Aretherepresentlypendingagainstyouanycriminalcharges?

c Yes c No

19a.Haveyoueverbeenconvictedof,pledguiltytoornolocontendretoafelony?

c Yes c No

19d.Haveyoueverbeenconvictedofaviolationofanystateorfederallawrelatingtoalcoholicbeverages,or forfeitedanybondwhileanysuchchargewaspendingagainstyou?

c Yes c No

24a.Isyourspouseoranyfamilymember(s)workinginanyareaoftheliquorindustry?

c Yes c No

24b.Ifyes,forwhom?

25a.Areyouamemberofanyboardorcommission,oranagentoranemployeeofthestateofOklahomaorany politicalsubdivisionthereof?(County,City,TownorSchoolDistrict)

c Yes c No

25b.Ifyes,explain


INDIVIDUAL QUESTIONNAIRE (continued)

27a.Doesyourinterestresultinexerciseofcontrolover,orparticipationinthemanagementofthe manufactureorwholesaler’sbusinessorbusinessdecisions?

c Yes c No

26a.Doyouindividually,orthelegalentitytobelicensed,haveanyright,title,lien,claimorotherinterest, financialorotherwise,in,uponortothepremises,equipment,businessofanyABLECommissionLicense?

c Yes c No

28a.Areyoualawenforcementofficial,apeaceofficerengaginginlawenforcementactivitiesorapersonwho appointslawenforcementofficials?

c Yes c No

26b.Ifyes,explain

27b.Ifyes,explain

28b.Ifyes,explain

29. AreyouanemployeeoforrelatedtoanymemberoftheABLECommissionortotheDirectororAssistant Directorbyaffinityorconsanguinitywithinthethirddegree?

c Yes c No

30. Areyouajudge,districtattorneyorpublicofficialwhositsinajudicialcapacitywithjurisdictionoverthe OklahomaAlcoholicBeverageControlAct?

c Yes c No

31. AreyouanemployeeoftheOklahomaTaxCommissionengaginginauditing,enforcingorcollectingof alcoholicbeveragetaxes?

c Yes c No

I, _________________________________, under penalty of law, swear that I have read allinformationprovidedinthisdocumentandanyattachmentsandtheinformationistrueandcorrect.Ialsounderstandanyfalsestatementorrepresentationinthisapplicationcanresultinmyapplicationbeingdeniedand/orcriminalchargesbeingfiledagainstme.IalsoauthorizetheABLECommissiontousealllegalmeanstoverifytheinformationprovided.IauthorizeanypersonororganizationlistedinthisapplicationtoprovideinformationaboutmetoanAgentoftheOklahomaAlcoholicBeverageLawEnforcementCommissiononaconfidentialbasis,includingbankandfinancialrecords,criminalhistoryrecords,drivingrecords,taxrecordsandanyotherinformationrelatingtocharacterorfitnessforaliquorlicense.IwillimmediatelynotifytheABLECommissionifaLicensee-Wholesalerconnectionasdescribedinthequestionnaireaboveexistsoriscontemplatedinmybusiness.

_________________________________________________ Signature of Applicant

_________________________________________________ Title


LOCATION DIAGRAMDraworattachadiagramofthelicensedpremises.Thediagramshouldincludethefollowing:outside dimensions, rooms, doorways, bars and liquor storage areas. DO NOT SUBMIT BLUEPRINTS


NOTICE OF INTENTION TO APPLY FOR AN ALCOHOLIC BEVERAGE LICENSE

1. Complete in detail2.Copytonewspaperforpublication3.Saidnoticeshallbepublished innot less than2column inches ina legalnewspaperof generalcirculationinthecountyinwhichlicensedpremisesaretobelocated.4.Thenoticewillbetwicepublished,onceeveryeight(8)daysfortwo(2)successiveweeks.5.Submitoriginalwithapplication.

In accordance with Title 37, Section 522 and Title 37A, Section 2-141

_______________________________________________________________________________

_______________________________________________________________________________

a/an_______________________________________________________________herebypublishes

noticeof__________ intention toapplywithinsixtydays from thisdate to theOklahomaAlcoholic

BeverageLawsEnforcementCommissionfora__________________________________________

LicenseunderauthorityofandincompliancewiththesaidAct:That_________intend(s),ifgranted

such license to operate as a _________________________________________ establishment

with business premises located at _________________________________________________

in ___________________, ___________________, Oklahoma under the business name of

__________________________________________________________________________________

Datedthis_________________________dayof_______________________________,20_______

Signature of applicant(s): if partnership, all partners must sign. If corporation, an officerof the corporation must sign. If limited liability company, a manager must sign. If tribe, atribalmembermustsign.

________________________________ ________________________________

________________________________ ________________________________

Countyof___________________,Stateof___________________

Beforeme,theundersignednotarypublic,personallyappeared:

______________________________________________________________________________to me known to be the person(s) described in and who executed the foregoing application and

acknowledgedthat_____________executedthesameas_____________freeactanddeed.

____________________________________________________________

nameandaddressofindividual,partners,limitedpartnership,corporation,limitedliabilitycompany,tribeortribalcorporation

city county

individual,partnership,limitedpartnership,corporation,limitedliabilitycompany,tribeortribalcorporation

Wine&SpiritsWholesaler,BeerDistributor,RetailBeer,RetailWine

Wine&SpiritsWholesaler,BeerDistributor,RetailBeer,RetailWine

his,her,its,their

he,she,it,they

he,she,they

NotaryPublic Mycommissionexpires

his,her,their


I do hereby declare, under penalty of perjury, that ______________________________________

did cause to be published in a legal newspaper of general circulation in the county

of ___________________ located in the city of ______________________,Oklahoma by causing

the same to be published on the _______ day of ____________________, 20________ and on

the _______ day of ____________________, 20________, a notice of intention to apply for an

ABLECommissionLicense,andthatatruecopyofsaidnoticeisattachedandmadeaparthereof.

________________________________________

Subscribedandsworntobeforemethis_______dayof____________________,20______.

____________________________________________________________

1.Attachacopyofeachrunofthepublication.2.Submitoriginalcompletedproofofpublicationwithapplication.3.Youmaysubmitthepublisher’saffidavitforminplaceoftheaboveaffidavit.

Nameoflegalnewspaper

Legalrepresentativeofthenewspaper

PROOF OF PUBLICATION

NotaryPublic Mycommissionexpires