Application For E Permit {DLC 4079}

OHIO DEPARTMENT OF COMMERCE DIVISION OF LIQUOR CONTROL 6606 TUSSING ROAD, P.O. BOX 4005 REYNOLDSBURG, OHIO 43068-9005 Telephone No. (614) 644-3155 http://www.com.ohio.gov/liqr APPLICATION FOR E PERMIT PERMIT FEE - $500.00 APPLICATION PROCESSING FEE - $100.00 § 4303.19 E permit. - Permit E may be issued to the owner or operator of any railroad, a sleeping car company operating dining cars, buffet cars, club cars, lounge cars, or similar equipment, or an airline providing charter or regularly scheduled aircraft transporation service with dining, buffet, club, lounge, or similar facilities, to sell beer or any intoxicating liquor in any such car or aircraft to bona fide passengers at retail in glass and from the container for consumption in such car or aircraft, including sale on Sunday between the hours of one p.m. and midnight. The fee for this permit is five hundred dollars. TYPE OR PRINT PLAINLY Name of Applicant: Out of State Address: Ohio Address: Mail Permit and Correspondence To: ALL QUESTIONS MUST BE ANSWERED City: City: State: State: OH Zip Code: Zip Code: Address: Name: City, State, & Zip: Applicant operates: Railroad Airline Sleeping Car Company ANSWER ALL QUESTIONS ON PAGE TWO FOR DIVISION USE ONLY Coder: Taxing District Permit Number Receipt # Remarks: Reviewer Action: DLC 4079 EOE/ADA SERVICE PROVIDER Page 1 FOR TTY USERS DIAL ORS 1-800-750-0750 Rev. 9/2010 American LegalNet, Inc. www.FormsWorkFlow.com 1. Have you or any partner, office holder, managing member, 5% stockholder or member, spouse or other person involved in this permit ever been refused a permit, denied a renewal, or had a permit revoked from another state, by this Division, or the Liquor Commission? If YES, attach a written explanation. 2a. Have you or any partner, office holder, managing member, or 5% stockholder or member, spouse or other person involved in this permit, ever been convicted of a felony or any misdemeanor, including any alcohol related offenses? IF YES, attach a written explanation. 2b. If applicant is a sole proprietor or partnership, will spouse work on permit premises? If YES , indicate spouse's full name YES NO YES YES NO NO 3. Do you have departures scheduled from Ohio airports/railstations? If YES, attach a list of all airports/railstations in Ohio. 4. Do you or any partner, office holder, managing member, stockholder, employee, spouse, or other person involved in this permit own any stock or have any interest in the business of a manufacturer or wholesale distributor of alcoholic beverages? If YES, attach a written explanation. YES NO YES NO DELIBERATE MISREPRESENTATION OF ANY OF THE INFORMATION ON THE APPLICATION CAN RESULT IN THE DIVISION'S REFUSING TO APPROVE THIS APPLICATION. NOTE: Your permit certificate is issued for a permit period that expires October 1st each year and is renewed annually on that date. If your permit is issued after April 1st, you will receive a 50% refund of the class fees paid, not including the $100.00 application fee. THE FOLLOWING MUST BE COMPLETED BY THE APPLICANT(S): State of Ohio, I, (Please Print) County, ss being first duly sworn, according to law, depose and say that the statements and answers made in the foregoing application are true. ___________________________________________________________________________ (Signature of Individual, Partner, Officer, Managing Member, or 5% or more Stockholder or Member) _____________________ (Title) _______________ (Date) (Residence Address) (City) (State) (Zip Code) (Area Code & Telephone Number) (To be completed by Notary Public) Sworn to before me and subscribed in my presence this ______________day of _____________________________________, 20 _____________. ________________________________________ (Notary Public) _______________ (Notary Expiration) Page 2 American LegalNet, Inc. www.FormsWorkFlow.com