Application For Nonprofit Arts Organization Liquor License {LIQ 612}

For Office Use Only Licensing and Regulation PO Box 43085 Olympia WA 98504-3085 360/664-1600 Fax: (360) 753-2710 www.lcb.wa.gov Date Check No. Amount Rec'd Rec'd By License No. Application for Nonprofit Arts Organization Liquor License 1. 2. The application fee is $266. Please make your check payable to WSLCB Mail your check to Licensing and Regulation, PO Box 43085, Olympia, WA 98504-3085 Questions? Please call Customer Service at (360) 664-1600 A Nonprofit Arts Organization liquor license is issued to a bona fide nonprofit organization to sell beer, wine and spirits in conjunction with artistic or cultural exhibitions or performances (see page 2 for more information). Applicant Information 1. Organization name Mailing address Street/Route/PO Box Liquor license address (if different) Phone 2. ( ) Street/Route/PO Box City City State State Zip Zip Name of person responsible for day-to-day operations Business Phone E-mail address ( ) Home Phone ( ) Organization Information 1. 2. Number of members in organization Is association registered as a nonprofit organization with the Washington Secretary of State?...................................................................................................................... Secretary of State File No: 3. 4. 5. Does the organization have any interest, financial or otherwise, in any manufacturer, distributor or importer of beer, wine or spirits?........................................................... Does a manufacturer, distributor or importer of beer, wine or spirits have any interest in the organization, financial or otherwise?..................................................... Will any of the members, officers or directors receive direct or indirect monetary payment from the proceeds of the sale of liquor?........................................................ If yes, please attach explanation and indicate amount. Current Officers of the Organization Name (attach additional sheets if necessary) Mailing Address Phone Number Date of Birth YES YES YES NO NO NO YES NO LIQ 612 7/15 *LCB LIQ612* American LegalNet, Inc. www.FormsWorkFlow.com LIQ 612 7/15 American LegalNet, Inc. www.FormsWorkFlow.com Current Directors of the Organization Name Mailing Address (attach additional sheet if necessary) Phone Number Date of Birth Qualifications and Certification As representative of the applicant organization, I certify the organization meets the following requirements: 1. The organization is organized and operated for the purpose of providing artistic or cultural exhibitions, presentations or performances or cultural or art education programs for attendance by the general public, which includes: An exhibition or presentation of works of art or objects of cultural or historical significance (such as those commonly displayed in an art or history museum) or A musical or dramatic performance or An educational seminar or program on an artistic, cultural, or historical subject. 2. The organization is a bona fide not-for-profit corporation (per RCW 24.03) managed by a governing board (Directors) of not less than eight individuals, none of whom is a paid employee of the organization. 3. In addition, the corporation satisfies the following conditions: No part of its income is paid directly or indirectly to its members, stockholders, officers, directors or trustees, except in the form of services rendered to the corporation in accordance with its purposes and bylaws. Salary or compensation paid to officers and executives is only for actual services rendered and at a level comparable to the salary or compensation of like positions within the state. Assets of the corporation are dedicated to the activities for which the license is granted. Upon the liquidation or dissolution of the corporation, the assets will not benefit any member or individual except a nonprofit organization. The proceeds from the sale of liquor (except reasonable operation costs) will be used to further the purpose of the organization. Services are available regardless of race, color, national origin or ancestry. The Liquor Control Board shall have access to the corporation's books in order to determine whether the corporation is entitled to a liquor license. Print Name Title Officer's Signature Date LIQ 612 7/15 American LegalNet, Inc. www.FormsWorkFlow.com