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STATE OF OKLAHOMA OKLAHOMA ALCOHOLIC BEVERAGE LAWS ENFORCEMENT COMMISSION APPLICATION CHECK LIST FOR BOTTLE CLUB, CATERER, BREWER, DISTILLER, OKLAHOMA WINEMAKER, RECTIFIER, SACRAMENTAL WINE, AND WINEMAKER LICENSE APPLICANTS GENERAL APPLICATION INSTRUCTIONS: Complete all items on Check List page 1 and applicable items on Check List page 2. The documents requested below are required for a license application. ALL documents indicated must be provided. All documents must be legible and complete. Applicant may be an Individual, a General or Limited Partnership, a Corporation, or a Limited Liability Company. When an applicant's signature is required, individuals must sign for themselves. If the applicant is a Partnership, each partner must sign; Limited Partnership, general partner must sign; Corporation, a corporate officer must sign; Limited Liability Company, a manager must sign. Mail original application and supporting documents with one additional copy to: Oklahoma ABLE Commission, 3812 North Santa Fe, Suite 200, Oklahoma City, OK 73118. Walk-in application are accepted 7:30 a.m. to 4:00 p.m. Monday - Friday. Questions concerning this application or application process should be directed to the Licensing Division at the above address, Telephone (405) 521-3484; Fax (405) 521-6578. I. Application packet supplied by the Commission to be completed by Applicant. ____ 1. Application Page 1. Complete the top of the page. Mark the license for which you are applying. Only one license per application. Complete and sign the oath in the middle of the page and have signature notarized. ____ 2. Application Page 2. Complete both sections: Statement of Main Purpose and Location Affidavit to include the signature of applicant. To complete the Location Affidavit you must circle is or is not in two places. ____ 3. Application Page 3. Complete all questions. ____ 4. Application Page 4. Applicant signs. ____ 5. Application Pages 5,6,7,8,9. Each Individual must complete separate pages. Complete all questions, sign and notarize in appropriate places. The individuals required to complete are individual sole proprietors, each partner, limited partner, corporate officer, corporate director, corporate stockholder owning 15% or more of the issued stock, and all limited liability company managers and members. ____ 6. Application Page 10A. Corporations must complete. Limited partnerships must complete on a corporate general partner and any corporate limited partner. If a stockholder in the corporation is another corporation, the corporation that owns the stock must submit a page 10A, Corporate Questionnaire, and a financial statement. If a stockholder in the corporation is a limited liability company, the company that owns the stock must submit a page 10B, Limited Liability Company Questionnaire, and a financial statement. ____ 7. Application Page 10B. Limited Liability Companies must complete. If a member is a corporation the corporation which holds the membership must submit a page 10A, Corporate Questionnaire, and a financial statement. If a member is another limited liability company the limited liability company which holds the membership must submit a page 10B, Limited Liability Company Questionnaire, and a financial statement. ____ 8. Application Page 11. Hand sketch a diagram of the premise that is to be licensed. Do not submit oversized blueprints. ____ 9. Application Pages 12 & 13. Complete all sections. Individuals and each partner must complete a personal financial statement, including business. Corporations, limited partnerships, limited liability companies complete for the entity being licensed. Limited partnerships must also submit financial statements for the general partner and any limited partner in the partnership. Bank addresses, account numbers, account signers, and account types must be listed. ____ 10. Application Page 14. Complete and take a copy to newspaper. Submit original to Commission. Directions on bottom of page 14. ____ 11. Application Page 15. Complete or attach proof of publication affidavit. Directions on bottom of page 15. Application must be received within sixty (60) days of the first publication date. ____ 12. License Fee. Enclose a personal check, business check, cashier's check or money order in the correct amount with the application made payable to the ABLE Commission. Fee amounts are listed on the back of the check list. ____ 13. Copies. The original, completed application (Pages 1-15) and the required supporting documents with ONE ADDITIONAL COPY OF ALL must be submitted to the Commission. Additional documentation may be required during the investigation. II. Documentation Supplied by Applicant (complete applicable section only). _____ INDIVIDUAL SOLE PROPRIETORS MUST PROVIDE: ____ 1. Statement of Financing. Written verification of the amount and source of finances used to start the business. Documentation of source is required. If borrowing funds, you must provide detailed loan information. ____ 2. Proof of Liability Insurance Covering both bodily injury and property damage. ____ 3. Deed or Lease. A copy of a deed; a lease; a purchase agreement; or a sales contract must be provided for the proposed licensed premise. Documentation must be in the name of the individual. ____ 4. Certificate of Compliance. Written verification of zoning, fire, safety, and health code compliance from the city. If there are no zoning, fire, safety CONTINUED ON CHECK LIST PAGE 2 ABLE Form Lic-11 Revised 8/14 CHECK LIST PAGE 2 ____ 5. or health codes, a statement from the city is needed stating no such codes exist. If proposed premise is outside city limits, verification of code compliance must be provided by the Board of County Commissioners. Cannot be over sixty (60) days old. Tax statement. Statement or receipt proving payment of ad valorem taxes, including real and personal, on ANY property owned in the state and from the county where the premise to be licensed is located stating no taxes are owed. Receipts or statements must be in the name of the individual. Cannot be over sixty (60) days old.*THIS STATEMENT COMES FROM THE COUNTY TREASURER’S OFFICE _____ CORPORATIONS MUST PROVIDE: ____ 1. Corporate Documents. ____ A. Certificate of Incorporation ____ B. Certificate of Good Standing from the Secretary of State. (Must be original. Cannot be over sixty days old.) ____ C. Minutes designating current officers and directors. ____ D. Minutes authorizing application for liquor license. ____ 2. Statement of Financing. Written verification of the amount and source of finances used to start the business. Documentation of source is required. If borrowing funds, you must provide detailed loan information. ____ 3. Proof of Liability Insurance Covering both bodily injury and property damage. ____ 4. Deed or Lease. A copy of a deed; a lease; a purchase agreement; or a sales contract must be provided for the proposed licensed premise. Documentation must be in the name of the corporation. ____ 5. Certificate of Compliance. Written verification of zoning, fire, safety, and health code compliance from the city. If there are no zoning, fire, safety or health codes, a statement from the city is needed stating no such codes exist. If proposed premise is outside city limits, verification of code compliance must be provided by the Board of County Commissioners. Cannot be over sixty (60) days old. ____ 6. Tax statement. Statement or receipt proving payment of ad valorem taxes, including real and personal, on ANY property owned in the state and from the county where the premise to be licensed is located stating no taxes are owed. Receipts or statements must be in the name of the corporation. Cannot be over sixty (60) days old.*THIS STATEMENT COMES FROM THE COUNTY TREASURER’S OFFICE _____ GENERAL & LIMITED PARTNERSHIPS MUST PROVIDE: ____ 1. Partnership Agreement. Agreement listing all partners and/or limited partners and detailing each partner's ownership interest in the business. ____ 2. Statement of Financing. Written verification of the amount and source of finances used to start the business. Documentation of source is required. If borrowing funds, you must provide detailed loan information. ____ 3. Proof of Liability Insurance Covering both bodily injury and property damage. ____ 4. Deed or Lease. A copy of a deed; a lease; a purchase agreement; or a sales contract must be provided for the proposed licensed premise. Documentation provided must be in all partner's names in a general partnership or the partnership name of a limited partnership. ____ 5. Certificate of Compliance. Written verification of zoning, fire, safety, and health code compliance from the city. If there are no zoning, fire, safety or health codes, a statement from the city is needed stating no such codes exist. If proposed premise is outside city limits, verification of code compliance must be provided by the Board of County Commissioners. Cannot be over sixty (60) days old. ____ 6. Tax statement. Statement or receipt proving payment of ad valorem taxes, including real and personal, on ANY property owned in the state and from the county where the premise to be licensed is located stating no taxes are owed. All partners must have tax statements for themselves. Limited partnerships must have statements for the partnership, the general partner, and all limited partners who own 15% or more interest in the partnership. Cannot be over sixty (60) days old.*THIS STATEMENT COMES FROM THE COUNTY TREASURER’S OFFICE _____ LIMITED LIABILITY COMPANIES MUST PROVIDE: ____ 1. Certificate of Good Standing. Issued by the Secretary of State. (Must be original. Cannot be over sixty days old.) Filed with the Secretary of State with all ____ 2. Articles of Organization. amendments and corrections. ____ 3. Limited Liability Company Operating Agreement & Issued Certificates of Membership Interest. Copies issued to each member. ____ 4. Proof of Liability Insurance Covering both bodily injury and property damage.. ____ 5. Statement of Financing. Written verification of the amount and source of finances used to start the business. Documentation of source is required. If borrowing funds, you must provide detailed loan information. ____ 6. Deed or Lease. A copy of a deed; a lease; a purchase agreement; or a sales contract must be provided for the proposed licensed premise. Documentation provided must be in the name of the Limited Liability Company. ____ 7. Certificate of Compliance. Written verification of zoning, fire, safety, and health code compliance from the city. If there are no zoning, fire, safety or health codes, a statement from the city is needed stating no such codes exist. If proposed premise is outside city limits, verification of code compliance must be provided by the Board of County Commissioners. Cannot be over sixty (60) days old. ____ 8. Tax statement. Statement or receipt proving payment of ad valorem taxes, including real and personal, on ANY property owned in the state and from the county where the premise to be licensed is located stating no taxes are owed. Limited Liability Companies must have statements for the company. Cannot be over sixty (60) days old.*THIS STATEMENT COMES FROM THE COUNTY TREASURER’S OFFICE ABLE Form Lic-11 Revised 8/14 EFFECTIVE May 28, 2010 In accordance with the passage of House Bill 3383, a surcharge shall be paid in addition to the applicable licensing fee and administrative fee, if required. The surcharge fees are listed below and shall be assessed annually for the following licenses at the time of submitting new and renewal applications. The license fee, surcharge and administrative fee payments can be made in one payment. Failure to submit the license application, license fee, administrative fee and surcharge will cause an application to be delayed or denied. A copy of the bill can be viewed on our website www.able.ok.gov. Please direct questions to the Licensing Division 405-521-3484. Non-Resident Seller Wholesale Class B Wholesale without an active low-point beer license Class B Wholesale with an active low-point beer license Package Store for cities and towns over 5,000 population Package Store for cities and towns from 2,501 to 5,000 population Package Store for cities and towns from 200 to 2,500 population Mixed Beverage Mixed Beverage/Caterer Combination Caterer Beer and Wine $2,500 $2,500 $1,000 $1,500 $250 $200 $150 $25 $25 $25 $25 OKLAHOMA ALCOHOLIC BEVERAGE LAWS ENFORCEMENT COMMISSION SCHEDULE OF LICENSE FEES TYPE OF LICENSE LICENSE FEE/RENEWAL Add-A-Partner(AAP) 10% of Amount of the Original License Fee Airline(AAA) 1,005.00/905 Beer & Wine(BAW) 525.00/475 Bonded Warehouse(BWH) 190.00/190 Bottle Club(BOT) 1,000.00/900 Bottle Club Fraternal(BCF) 500.00/500 Carrier(CAR) 23.00/23 Caterer(CAT) 1,030.00/930 Caterer/Mixed Beverage Combination(CMB) 1,525.00/1,525 Change of Corporate Officers(CCO) 100.00 Change of Stockholders(COS) 100.00 Change of Managers(LLC) 100.00 Change of Members (LLC) 100.00 Change of Location(MXB, BOT, & CMB ONLY) 100.00 Charity Games Organization(CGO) 100.00/100 Charity Games Exempt Organization(CXO) 0.00 Charity Games Manufacturer(CGM) 2,000.00/2,000 Charity Games Distributor(CGD) 5,000.00/5,000 Charitable Alcoholic Beverage Event(CAB) 55.00 Charitable Alcoholic Beverage Auction(CAU) 1.00 Cider/Wine/Strong Beer Permit(CWP) 0.00 Class B Wholesaler(CBW) 1,625.00/1,625 Class B Wholesaler-with active low-point beer license(CBW) 2,125.00/2,125 Distiller(DIS) 3,125.00/3,125 Hotel Beverage(HOT) 1,005.00/905 Industrial(IND) 23.00/23 Manufacturers Agent(MFA) 55.00/55 Mixed Beverage(MXB) 1,530.00/1,430 Mixed Beverage Fraternal(MXF) 500.00/500 Non-Resident Seller(NRS) 3,250.00/3,250 prorated7/1 through 6/30 Oklahoma Brewer(OKB) 125.00/125 Oklahoma Winemaker(OKW) 75.00/75 Public Event Annual(PEV) 1,030.00/1,030 Public Event-One (1)Time(PUE) 255.00 Railroad(RRR) 100.00/100 Rectifier(REC) 3,125.00/3,125 Retail (Population as recorded in the last Federal Decennial Census)(RET) A - 200 to 2,500 population 455.00/455 B - 2,500 to 5,000 population 805.00/805 C - Over 5,000 population 1,155.00/1,155 Special Event Annual(SPE) 55.00 Special Event Quarterly(SPQ) 55.00 Storage(STO) 23.00/23 Wholesaler(WHO) 6,000.00/6,000 Winemaker(WIN) 625.00/625 Winemaker Self-Distribution(WSD) 750.00/750 PAGE 1 OKLAHOMA ALCOHOLIC BEVERAGE LAWS ENFORCEMENT COMMISSION APPLICATION The filing of this application does not commit the Commission to the granting of the license that you are applying for, nor does it permit you to operate the business named below before the granting of the license. LICENSEE NAME_____________________________DOING BUSINESS AS NAME____________________ PREMISE LOCATION____________________________________________________________________ _____________________________________________________________________________________ Check the type of application: ___ Add-A-Partner ___ Class B Wholesaler ___ Retail Store ___ Airline/Railroad ___ Distiller ___ Sacramental Wine ___ Beer & Wine ___ Industrial ___ Storage ___ Bonded Warehouse ___ Mixed Beverage ___ Wholesaler ___ Bottle Club ___ NonResident Seller ___ Winemaker ___ Brewer/Oklahoma Brewer ___ Oklahoma Winemaker ___ Winemaker Self ___ Carrier ___ Rectifier Distribution ___ Caterer ___ Caterer/Mixed Beverage Combo ___ Change of Corporate Officers ___ Change of Managers or Members _____________________________________________________________________________________ OATH State of Oklahoma ) ss. County of___________________) _______________________________________, being first duly sworn upon oath deposes and says: That he is the applicant who makes the above and foregoing application; that he has read and signed the same, knows the contents thereof and that all statements therein contained are true. Applicant(s) certifies that the statements and representations made herein are true and correct and consents that if any statements or representations herein are found to be false or omitted, that the Director may refuse to issue said license or may cause such license to be revoked forthwith at any time. He further agrees that he has filed all appropriate property with the County Assessor and that all ad valorem taxes assessed on his property, both real and personal, and wherever situated in the State of Oklahoma, have been paid. _____________________________________________________________________________________ Signature of Applicant(s) Subscribed in my presence and sworn of____________________________, 20_____. ___________________________ My commission expires: to before me this_______day ____________________________________________________ Notary Public ------------------------------------------------------------------------------------DO NOT WRITE IN THIS SECTION - CITY/COUNTY USE ONLY In accordance with Title 37, Section 517, this notice is being mailed to you for recommendations as to whether or not this applicant should be issued a license in your city/county, by the ABLE Commission. You have twenty (20) days to respond. Please complete the following and submit a notarized copy of this page only to: ABLE COMMISSION, 3812 N. Santa Fe, Suite 200, Oklahoma City, Oklahoma 73118 (Attach additional page, if necessary.) Grant_______ Deny_______ Reasons for denial _________________________________________ ____________________________________________________________________________________ __________________________________________________ Signature of City/County Official __________________________________________________ Title Subscribed and sworn to before me this______day of__________________, 20____. ________________________ My commission expires: _______________________________________________ Notary Public ABLE Form Lic-075-01 Revised 3/09 PAGE 2 OKLAHOMA ALCOHOLIC BEVERAGE LAWS ENFORCEMENT COMMISSION STATEMENT OF MAIN PURPOSE AFFIDAVIT certify I, that the main business for which a liquor license is being requested is: of business or sale which will produce restaurant, bar, retail store, etc. purpose of (State the type the majority of the Terms "recreation" such as the income, ie. or "entertainment"are too vague.) LOCATION AFFIDAVIT (circle correct responses) I, certify that the business location for which a license is being requested is/is not within three hundred(300') feet of a church or public school. Signature of Applicant Date (if sole proprietor), all partners, (if partnership), General Partner (if limited partnership), Manager or Member (if an LLC) or Corporate Officer (if a corporation) . ABLE Form Lic-075-02 Revised 06/09 3 PAGE OKLAHOMA ALCOHOLIC BEVERAGE LAWS ENFORCEMENT COMMISSION 1. Name (s) of Individual Appl icant, Partners, Limi ted Partnership, Corporation, or Limited Liability Company (include social security number or federal employer identification number) : 1. (Name) (Address) (City, State) (Zip) (SSN!FEI) 2. 3. 4. 2. Is License to be Issued to: Individual Partnership Corporation Limited Liability Company 3. Doing Business Name of Premises: 4. Premises Address: (Number,Street,RuraI Route) (City) 5. (County) (State) (Zip) Business Mailing Address: (If different than #4 above) (City) (P a.Box, No., Street, (State) R,R,) (Zip) ____yes _ _ _No 6. Was Premises Previously Licensed by the Commission: 7. If Yes, to Whom? B. Former Premises Name: 9. The Local Governing Body Where the Premises is Located: Type of License: (Name of City or County) 10. Application Contact Person: (Address) (Tel.No: Home/Business/Message) SIGNATURE OF APPLICANT(S) 1. (Individual, Partners, General Partner of a Limited Partnership, Authorized Corporate Officer, 2. Manager of a Limited Liability Company) 3. 4. DATE ABLE Form Lic-075-03 Revised 1/07 PAGE 4 OKLAHOMA ALCOHOLIC BEVERAGE LAWS ENFORCEMENT COMMISSION CONFIDENTIAL DISCLOSURE I, ____________________________________ (PLEASE person or organization listed in this about me to an Agent of the Commission criminal on a history Oklahoma confidential records, PRINT) application Alcoholic hereby to authorize any provide information Beverage Laws Enforcement basis, including bank and financial records, driving information relating to character records, tax records and any other or fitness for a liquor license. Authorized signature of Applicant Title ABLE Form Lic-075-04 Revised 1/07 PAGES OKLAHOMA ALCOHOLIC BEVERAGE LAWS ENFORCEMENT COMMISSION INDIVIDUAL HISTORY ALL BLANKS MUST BE FILLED IN. PLEASE PRINT. IF THE QUESTION DOES NOT APPLY TO YOU, PLACE N/A (NOT APPLICABLE) IN THE SPACE. 1. Name (Last) (First) (Middle) 2. Othe r Names Used--,-----('""'Mc-a--.,i-d:-e-n---,--)- - - - - - - - - - - - , - - - - - (O-=-t7"h-e--c),-----------­ r 3. Add re s S --;-:-:---;--------O----:::,----,---.,-----------;-=-;------c--------,--::c-,---,---------O-=--c---;­ (Number and Street) (City) (State) (Zip) 4. SSN 5. Drivers Lic.No./State 6. Height 7. Sex 8. Spouses Place of Employment 9. Spouse Licensed by the Commission? 10. Home Phone ( 11. U.S. Citizen Yes 12 . I f a Natural i zed Ci t i zen-----(;cw-:;h,---e-n-a-n-d~w;-:;-h-e-r-e---;),------------------- _ Date of Birth _ ______ Age __ Place of Birth_---,--;-,--­ (City/State/Country) Weight _ Hair Co10r _ Eyes _ Name of Spouse _ _ _ Yes _ No Business Phone _ NO _ If "No" List Alien Reg. No. _ CRIMINAL RECORD Note: A criminal records check is made on all license applicants in the normal processing of a license application. The information provided in Questions 1 through 12 below can protect you from an error in the criminal records check. 12A. Have you ever been convicted of, pled guilty to, or nolo contendre to felony? Yes No a 12B. Have you been convicted of any crime, violation, or infraction of any law? (Do not include minor traffic violations for which a fine or bail forfeiture of $50 or less was imposed.) Yes No 12C. Are there presently pending against you any criminal charges? (Do not include minor traffic violations for which a fine or bail forfeiture of $50 or less was imposed.) Yes No 120. Have you ever been convicted of a violation of any state or federal law relating to alcoholic beverages, or forfeited any bond while any such charge was pending against you? Yes No 12E. If you have answered "Yes" to 12A through 120, list below: Offense Date City/County/State (Attach additional sheet if necessary.) ABLE Form Lic-075-05 Revised 5/95 Disposition (Fine, Probation, Incarceration) 6 PAGE OKLAHOMA ALCOHOLIC BEVERAGE LAWS ENFORCEMENT COMMISSION APPLICANT AFFIDAVIT I, , being first duly sworn, upon oath depose and say: that I am the applicant for a liquor license under the Oklahoma Alcoholic Beverage Control Act. I do hereby swear or affirm that I have read and do understand the current laws of the State of Oklahoma and the Rules and Regulations of the Oklahoma Alcoholic Beverage Laws Enforcement Commission, which pertain to the type of license for which I have made application. I further agree that if I am granted the license, I shall continue to familiarize myself with such laws, rules, and regulations, and any amendments and/or additions thereto. I further agree that if at any time I have employees working for me under my license I will insure that they familiarize themselves with the aforementioned laws, rules and regulations. I declare that I have not been convicted of a felony. I declare that I have not been convicted of a violation of any state or federal law relating to alcoholic beverages, nor have I forfeited a bond while any such charge was pending against me. I declare that I am not a person who appoints or is a law enforcement official, nor am I a peace officer engaging in law enforcement activities. I declare that I am not related to any member of the ABLE Commission or to the Director or Assistant Director by affinity or consanguinity within the third degree, nor am I an employee of the ABLE Commission or of the Director. I declare that I am not a judge, district attorney, or public official who sits in a judicial capacity with jurisdiction over the Oklahoma Alcoholic Beverage Control Act. I declare that I am not an employee of the Oklahoma Tax Commission engaging in auditing, enforcing, or collecting of alcoholic beverage taxes. I hereby declare that I will not violate any of the laws of the United States, laws of the State of Oklahoma, or the ordinances of any city in which the licensed premises are located in the conduct of the licensed business. Signature of Applicant State of Oklahoma County of Subscribed and sworn to before me this My commission expires: Notary Public ABLE Form Lic-075-06 Revised 1/07 day of 19 7 PAGE OKLAHOMA ALCOHOLIC BEVERAGE LAWS ENFORCEMENT COMMISSION Note: 1. The following questions refer to activity in the liquor industry in Oklahoma or any other State. Are you presently or have you been licensed or employed in the liquor business? No Yes License Type _ License Number _ When - - - - - - - - - Loca t i on 2. Have you ever received a warning, a notice of violation, fine, or revocation as a licensee? Yes 3. No No refused When a license _ to sell, serve, or dispense _ Locat i on _ Have you ever held or do you hold any financial interest in any liquor enterprise (manufacturing, importing, wholesale, or retail)? Yes 5. suspension, _ Loc a t ion When Have you ever been alcoholic beverage? Yes 4. _ No When _ Loca t i on _ Do you owe money to any manufacturer or distributor of wine, distilled spirits on account of cash or credit advanced? No Yes To Whom ? beer, or ---,-, _ Name Address 6. No For Whom? _ No When _ Are you related to any member of the Oklahoma Alcoholic Beverage Laws Enforcement Commission, Director, or Assistant Director by affinity or consanguinity within the third degree? Yes 9. Zip Have you ever held, as an Oklahoma resident, any federal liquor stamp prior to the adoption of Article XXVII of the Oklahoma Constitution? Yes 8. State Is your spouse or any family member(s) working in any area of the liquor industry? Yes 7. City No_ _ If "Yes" give name and relationship: _ Are you a member of any board or commission, or an agent or an employee of the State of Oklahoma or any political subdivision thereof? (County, City, Town, or School District.) Yes CAUTION: No If" Ye s" exp 1 a i n _ FALSIFICATION OR INTENTIONAL OMISSIONS OF INFORMATION GROUNDS TO DENY OR REVOKE YOUR APPLICATION FOR A LICENSEI Signature of Applicant ABLE FORM Lic-075-07 Revised 1/07 Date MAY BE PAGES OKLAHOMA ALCOHOLIC BEVERAGE LAWS ENFORCEMENT COMMISSION LIST CURRENT AND FORMER EMPLOYERS OR OCCUPATIONS DURING THE PAST TEN YEARS. (ATTACH ADDITIONAL SHEET IF NECESSARY.) Dates by Month/Year From Employer or Business To Occupation City and State Dates by Month/Year Employer or Business From City and State Dates by Month/Year Employer or Business City and State Dates by Month/Year Employer or Business City and State Dates by Month/Year Employer or Business Address To Occupation City and State Dates by Month/Year Employer or Business From Address To Occupation From Address To Occupation From Address To Occupation From Address Address To Occupation City and State LIST CURRENT AND FORMER RESIDENCES WHERE YOU HAVE LIVED IN THE PAST TEN YEARS TO INCLUDE ADDRESS (STREET, CITY, STATE). Dates by Month/Year From To __ From To __ From To __ From To __ Street, City and State ABLE Form Lic-075-08 Revised 1/07 9 PAGE OKLAHOMA ALCOHOLIC BEVERAGE LAWS ENFORCEMENT COMMISSION TIED-HOUSE DISCLOSURE A. TO BE ANSWERED IF APPLICATION MANUFACTURER OR WHOLESALER. 1. ANY LICENSE OTHER THAN No If yes, explain _ Do you, individually, or the legal entity to be licensed, have any right, title, lien, claim, or other interest, financial or otherwise, in, upon or to the premises, equipment, business, or merchandise of any manufacturer of or wholesale dealer in alcoholic beverages? Yes 3. FOR Has the business to be licensed been financed with money or property by any manufacturer of or wholesale dealer in alcoholic beverages? Yes 2. IS If yes, explain No _ Does your interest result in exercise of participation in the management of the wholesaler's business or business decisions? Yes control over, manufacturer's If yes, explain No or or _ I will immediately notify the Oklahoma Alcoholic Beverage Laws Enforcement Commission if a LICENSEE-WHOLESALER connection as described above exists or is contemplated in my business. (This notification extends to corporate officers, directors, and substantial stockholders.) Signature of Applicant for Retail, Mixed Beverage, Bottle Club, or Caterer Certification Date ***************************************************************************** B. TO BE ANSWERED LICENSE. 1. IF APPLICATION IS FOR A MANUFACTURER OR WHOLESALER Do you, individually, or the legal entity to be licensed, have the right, title, lien, claim or any other interest, financial or otherwise, in, upon or to the premises, equipment, business, or merchandise of any retailer, mixed beverage, bottle club or caterer of alcoholic beverages? Yes No If yes, explain _ I will immediately notify the Oklahoma Alcoholic Beverage Laws Enforcement Commission if a WHOLESALER-LICENSEE connection as described above exists or is contemplated in my business. (This notification extends to corporate officers, directors, and substantial stockholders.) Signature of Applicant for Wholesale or Manufacturer Certification ABLE Form Lic-075-09 Revised 1/07 Date 10A PAGE OKLAHOMA ALCOHOLIC BEVERAGE LAWS ENFORCEMENT COMMISSION CORPORATE QUESTIONNAIRE Type of License Licensee __ Trade Name Address Zip City Corporate Officers: Title Name SSN Address Board of Directors/Trustees/Executive Committee: Name SSN Address Stockholders: Name SSN Total shares authorized to issue Service Agent No. of Shares Held Address No. of shares issued (if applicable) Addre s s Date ABLE Form Lic-075-10 Revised 1/07 No. of shares unissued __ _ Signature of Corporate Officer 1OB PAGE OKLAHOMA ALCOHOLIC BEVERAGE LAWS ENFORCEMENT COMMISSION LIMITED LIABILITY COMPANY QUESTIONNAIRE Type of License Licensee Trade Name Address City _ Zip Limited Liability Company Managers: Title Name SSN Address SSN Address Limited Liability Company Members: Name Resident Agent Name Address Date ABLE Form Lic-075-10 Revised 1/07 Signature of Manager ___ PAGE 11 OKLAHOMA ALCOHOLIC BEVERAGE LAWS ENFORCEMENT COMMISSION Drawa diagram of the licensed premises. The diagram following: outside dimensions, rooms, doorways, bars, areas. Date should include the and liquor storage Signature of Applicant/Licensee Signature of Applicant/Licensee ABLE Form Lic-075-11 Revised 1/07 PAGE 12 OKLAHOMA ALCOHOLIC BEVERAGE LAWS ENFORCEMENT COMMISSION FINANCIAL STATEMENT NAME DOING BUSINESS NAME (Individual, Partner, Limited Partnership,Corporation, Limited Liability Company) l --'A'-'-"'-S""S-"'E"'T-"S'---CHECKING AT Financial Institution Name Address _ __ ~AM~O~UN~T~I ~O~T LIABILITIES TAXES DUE SCHEDULE 0 IOTHER I Account Signer(s) Name Account # Financial Institution Name Address Account Signer(s) Name I Account # Financial Institution Name Address Account Signer(s) Name Account # SAVINGS AT Financial Institution Name Address I Account # Financial Institution Name Address Account # EARNEST MONEY LEASE DEPOSIT OTHER CASH VALUE OF: Schedule A Schedule B Inventory Fixtures/Equipment Vehicles Schedule C Life Insurance Other TOTAL LIABILITIES NET WORTH I TOTAL LIABILITIES & NET WORTH TOTAL ASSETS 1. Last year's total income:$ Source: 2. Have you any assets or liabilities listed-oo thisflnancialS'tatement ?~-----Yes No If yes, explain why not included 3. Are-you-a-co~signer of any notes or contracts?-yes No~~~yes~xplarn-=====_ __ wt 4--:-HaVeyouaYnJudgmenrs;-suits;-liens:-rotax-warrantSfileaagainstYoU?----~-- Yes No__ If yes, explain~ _ ~ 5. Have you ever filed a petition of bankruptcy or been adjudged bankrupt? yes, expla in Applicant Signature ABLE Form Lic-075-12 Revised 1/07 ~ _ Yes No ~_ Date If 13 PAGE OKLAHOMA ALCOHOLIC BEVERAGE LAWS ENFORCEMENT COMMISSION FINANCIAL STATEMENT WORKSHEET NAME~~__~ ~~__ DOING BUSINESS NAME (Individual, Partner, Limited Partnership, Corporation, Limited Liability Company) Attach additional sheet if necessary. Schedule A STOCKS AND BONDS Number of Shares Description Market Value TOTAL RECEIVABLES - NOTES , CONTRACTS AND ACCOUNTS Schedule B Payment From (Name) Schedule C Terms I TOTAL - REAL ESTATE Type and Location of PrODertv Lein Holder ----­ Balance Due Date Income Per Month Mortgages Payment Present Terms Balance ---­ - Schedule 0 PAYABLES -T" Date Incurred To (Name) Market Value - - TOTAL_I CONTRACTS AND ACCOUNTS Payment Terms Balance Due IDate ICollateral Initial Current I --- I ---­ ------- --- ----I_­ I 1 Applicant Signature ABLE Form Lic-075-13 Revised 1/07 1==1 TOTAL Da t e I - - - - - _ 14 PAGE OKLAHOMA ALCOHOLIC BEVERAGE LAWS ENFORCEMENT COMMISSION NOTICE OF INTENTION TO APPLY FOR AN ALCOHOLIC BEVERAGE LICENSE In accordance with Title 37, Section 522 (name " address of liability company) individual, partners, limited partnership, corporation, or limited an/ a-----;--,---~-,-_=_--o---_=_---o-;_______;__,_____,_______o-_____;--~----_____;__,___-____o_.,____;____o_~__o_~;__--- (individual, partnership, limited partnership, corporation, limited liability company) hereby publishes notice of ____~;-------;----~-----;_____;~~._intention to apply (his, her, its, within their) sixty days from this date to the Oklahoma Alcoholic Beverage Laws Enforcement Commission for a (Beer & Wine, Brewer, Distiller, Rectifier, Winemaker, Wholesaler, Class B, Retail Store, Mixed Beverage, Bottle Club, Caterer, or Caterer/Mixed Beverage Combination) License under authority of and in compliance with the said Act: That intend(s), if granted such license to operate as a (he, she, it, or they) =- ~ -=-~__ ~~~--,---_~~establishment with business premises located at (Beer & Wine, Brewer, Distiller, Rectifier, Winemaker, Wholesaler, Class a , Retail Store, Mixed Beverage, Bottle Club, Caterer, or Caterer/Mixed Beverage Combination) (full street address or legal description) in Oklahoma, under the business (City) (County) name of (doing business name) Dated this day of 19 Signature of applicant (s): If partnership, all partners must sign. If corporation an officer of the corporation must sign. If limited liability company a manager must sign. County of _ _ _ _ _ _ _ _ _ _ _ _ , State of Oklahoma. Before me, the undersigned notary public, personally appeared; to me known to be the person(s) described in and who executed the foregoing application and acknowledged that executed the same (he/she/they) as -'(7h~i-s'/7h-e-r'/~t7h-e~i-r.)(Notary Public) free act and deed. (My commission expires) Instructions: 1. Complete in detail. 2. Copy to Newspaper for publication. 3. Said notice shall be published in not less than two column inches in a legal newspaper of general circulation in the county in which licensed premises are to be located. 4. The notice will be twice published, once every eight (8) days for (2) successive weeks. 5. Submit original with application. ABLE Form Lic-075-14 Revised 1/07 PAGE 15 OKLAHOMA ALCOHOLIC BEVERAGE LAWS ENFORCEMENT COMMISSION PROOF OF PUBLICATION I do hereby declare, under penalty of perjury, that (name of legal newspaper) did cause to be published in a legal newspaper of general Oklahoma, by causing the same to be published on the to , and on the apply for an in located in the City of the county of 19 circulation day of Alcoholic Beverage 19 License, day of , a Notice _ of Intention and that a true copy of said notice is attached and made a part hereof. Dated this day of _______________ , 19 _ (lsgal representativs of the newspaper) Subscribed and sworn to before me this My Commission Expires day of _________________ , 19 Notary Public Instructions: 1. 2. 3. Attach a true copy of each run of the publication. Submit original completed Proof of Publication with application. You may submit the publisher's affidavit form in place of the above affidavit. ABLE Form Lic-075-15 Revised 1/07 OKLAHOMA WHOLESALERS (Spirits & Wines) ACTION WHOLESALE LIQUOR Tad Shadid & Jeffrey Shadid 4200 Southeast 59th Oklahoma City, OK 73135-2511 (405) 682-8527 fax (405) 682-8559 jrod@actionliquor.com mikespoon@actionliquor.com K O BEVERAGE Larry Barnes 4157 S 72nd East Avenue Tulsa, OK 74145 (918) 728-7401 fax (918) 728-7402 kobeverage@tulsacoxmail.com CENTRAL LIQUOR COMPANY Franklin K. & Robert Z. Naifeh 605 North Tulsa P.O. Box 75447 Oklahoma City, OK 73147 (405) 947-8050 fax (405) 949-1416 Juanita@centralliquor.com SOUTHERN OKLAHOMA SPIRITS Tim J. McCullers 309 Mill Street Ardmore, OK 73401 (580) 223-0148 fax (580) 226-7180 DIXIE LIQUOR COMPANY Al J. Horton & Stacey Horton 300 North Jupiter Road Hartshorne, OK 74547 (918) 297-0133 fax (918) 297-0293 staceyk@dixieliquor.com FIREWATER SUPPLY CO Greg George, Owner 7220 E. 151st Street South PO Box 66 Bixby, OK 74008 firewater@olp.net (918)396-5600 fax (918)369-5604 JARBOE SALES COMPANY John B. Jarboe & John B. Jarboe II 6833 East Reading Place P.O. Box 580130 Tulsa, OK 74158 (918) 836-2511 (800) 669-2850 fax (918) 836-6688 mvaught@jarboesales.com LDF Wine & Spirits Theodore Solie 10718 East Marshall Street Tulsa, OK 74116 (918)437-7722 fax (918) 437-3502 STERLING WINES & SPIRITS CO Paul W. Dudman 2226 North Broadway Oklahoma City, OK 73103-4312 (405) 557-1818 fax (405) 557-1857 A KEITH BURT DIRECTOR AND SECRETARY TO THE COMMISSION MARY FALLIN GOVERNOR STATE OF OKLAHOMA ALCOHOLIC BEVERAGE LAWS ENFORCEMENT COMMISSION SHORT FORM PRICE REGISTRATION BY NON-RESIDENT SELLER & OKLAHOMA WINERIES Spirits & Wine License No. ________________________________________________ Name: ________________________________________________ Address: ________________________________________________ Date: _______________________________________________ In compliance with 45:30-3-3(b)(2) of the Oklahoma Administrative Code (OAC) the above named Non-resident Seller/Oklahoma Winery adopts by reference its most recent detailed price registration filed with the ABLE Commission __________________________, 20_____, for the month of ________________________________, 20_______, and affirms that said registration, without exception, will remain unchanged and in effect during the month of _______________________________, 20_______. It is hereby certified, under penalty of suspension or revocation of license that the above named licensee has on this date sent a true copy hereof to each Oklahoma licensed wholesaler. Non-resident Seller/Oklahoma Winery: ___________________________ By: ___________________________ 4545 NORTH LINCOLN BLVD., SUITE 270 • OKLAHOMA CITY, OK 73105 • (405) 521-3484 • FAX (405) 521-6578 An Equal Opportunity Employer