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2. License Number*
3. Registered Name*
4. Doing Business As
6. Establishment Address*
8. Licensee/Owner Name*
10. Address of Licensee*
12. Telephone Number*
13. Fax Number
14. E-Mail Address*
16. Best Means To Contact You*

    1. Mail

    1. E-mail

    1. Phone
18. How long have you been operating at your present location?*

    Please put number of years

19. Are you aware that you are prohibited from hiring employees that have been convicted of a crime?*

    1. Yes
    2. No
20. Do you own or lease the licensed premises?*

    1. Own
    2. Lease
22. Do you lease the active liquor license to another party?*

    1. Yes
    2. No
23. Please list their name and address*
25. In addition to serving liquor, do you offer the following?*

    1. Live Entertainment

    1. Amusement Devices, Coin-Operated; Picture Arcades

    1. Prepared Foods?
27. Do you have a current food handlers license?*

    1. Yes

    1. No
29. Are you under contract for pest control services?*

    1. Yes

    1. No
31. Please list their name, address, and phone number*
33. List the locations where you store your liquor stock*
35. Have the renovated, altered or enlarged your establishment during the last year?*

    1. Yes

    1. No
36. Provide Specific Details *
38. Name, address and phone number of your liquor beer distributor:*
40. Who runs the day to day operations on site at your establishment?*

    Please include name, title, address, and telephone number

42. C.o.d. Or credit basis with your listed distributor(s)? *

    1. Yes

    1. No
44. Emergency Contact*

    Please include name, address, and phone number

46. Is there off street parking for employees and patrons?

    1. Yes

    1. No
47. Indicate Exact Location*
49. Please List Your Hours of Operation*
51. Are there any tenants or occupants in the building other than the ABC licensed business?*

    1. No

    1. Residential

    1. Commercial
53. Your Latest E-141 A (ABC Employee List) Form*

    Upload Requested Documents Here

55. Electronic Signature Agreement*

    I certify that the foregoing statements made by me are true and accurate to the best of my knowledge. I am aware that if any of the foregoing statements made by me are willfully false, it shall affect my liquor license.

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
57. Name of individual licensee, general partner, corporation official*
Leave This Blank:


59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit

* indicates a required field