Representatives Permits Application {1012}

-30 APPLICATION FOR REPRESENTATIVES 1) 2) 3) Indicate type of permit you are applying for_____________________________________. Full Name of Applicant_______________________________________Age _________. Residence Address: Street: ________________________________________________. · City, Town, or Village:___________________________________________________. · Zip Code: __________________Telephone Number: __________________________. Name of Manufacturer or Wholesaler ________________________________________. ·License/Permit Serial No.:______________________ Telephone No.__________________. · Address of Premises ____________________________________________________. (Street, City, Town or Village, State and Zip Code) · County _______________________________________________________________. · Between what streets (if outside city limits and not known by bldg.#, specify location in relation to nearest road/highway)_______________________________ _____________________________________________________________________. · Has any changes in facts occurred since the signing of the application for the currently held permit which has not been reported to and acknowledged by the State Liquor Authority in accordance with the provisions of the S.L.A. Law. Yes __________ No ____________ (check one) 4) · If answer is yes, EXPLAIN ________________________________________________ ______________________________________________________________________. 5a) For Negotiator's Permit only: Is the applicant duly licensed to manufacture or sell alcoholic beverages at wholesale level in the state or country in which it is located? Yes ( ) No ( ) 5b) If a foreign manufacturer please attach a copy of the license or a letter from the Consular or governmental agency. SLA form 1012 revised 12/19/2011 American LegalNet, Inc. www.FormsWorkFlow.com 5c) List below the names and addresses of the representative (only two permitted) who will be authorized to conduct negotiations: NAME ADDRESS 5d) Indicate the type and brand names of the alcoholic beverages which will be offered to wholesalers in New York. If additional space is needed, please attach a list of the brand names. 6) Has the applicant or (if partnership) any of the partners, or (if a corporation) any of the officers, directors, or stockholders, or any agent or employee of the applicant, ever been CONVICTED (including pleas of guilty or suspended sentences) of any felony or of any other crime or offense of any kind except traffic violations? Yes ( ) No ( ) 7) If yes, please submit, in each case, a CERTIFICATE OF DISPOSITION or a CERTIFICATE OF CONVICTION by the Court Clerk. If yes please submit in each case, a CERTIFICATION OF DISPOSITION, a CERTIFICATE OF CONVICTION or a CERTIFICATE OF RELIEF FROM DISABILITIES FROM DISABILITIES from the Court Clerk. 8) Has the applicant or (if partnership) any of the partners or (if a corporation) any of the officers, directors or stockholders any interest, directly or indirectly, in any premises or business where any alcoholic beverage is manufactured or sold at wholesale or retail, whether by stock ownership, interlocking directors, mortgage or lein on, or ownership of any real or personal property, or by any other means including loans? Yes ( ) No ( ) If yes, set forth the location, any type of such business, the nature of the interest and the date when it was acquired. American LegalNet, Inc. www.FormsWorkFlow.com 9) Is the applicant or (if a partnership) any of the partners or (if a corporation) any of the officers, directors or stockholders a police commissioner or other police official, or subordinate of any police department, or a sheriff, deputy or under sheriff or any other peace officer? Yes ( ) No ( ) If yes, state name and title of such person. NAME TITLE THE FOLLOWING CERTIFICATION IS TO BE SIGNED AND DATED BY THE EMPLOYER OF APPLICANT 10) For Solicitors Permits -(Employers Name)________________________ certifies that (applicant's name)__________________________will be employed by them, and that they have compared the applicant's Drivers License or Non-Drivers ID photo with the applicant and that the enclosed DMV ID # and signature are that of the applicant. __________________________________________ (Signature of licensee or officer of corporation) ___________________ (Date) 11) State nature of business in which applicant is currently engaged:________________ _______________________________________________________________________ 12) Business Address: _______________________________________________________ ______________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com THE FOLLOWING PHOTO ID CARD AUTHORIZATION MUST BE COMPLETED AND SIGNED BY THE APPLICANT The State Liquor Authority produces Solicitor Permit Photo ID cards from records of the NYS Department of Motor Vehicles (DMV). If you have a current NYS Driver's License or Non-Driver ID card, please provide your 9-digit DMV ID number in the spaces provided and read and sign the informed consent below. If you do not have a photo NYS Driver's License or Non-Driver ID card, please visit any nearby NYS DMV office to obtain a Non-Driver ID BEFORE you complete and return this application. INFORMED CONSENT: I authorize the State Liquor Authority and DMV to produce an ID card bearing my DMV photo. I also understand that the State Liquor Authority and DMV will use my DMV photo to manufacture all subsequent ID cards for as long as I maintain my Solicitor's Permit. I understand that I can withdrawal consent for the use of this digitized image at any time. Requests for withdrawal must be submitted in writing to the State Liquor Authority. DRIVER's LICENSE ID #: |__|__|__|__|__|__|__|__|__| _________________________________________ (Applicant Signature) ________________ (Date) American LegalNet, Inc. www.FormsWorkFlow.com THE FOLLOWING CERTIFICATION MUST BE SIGNED AND DATED BY INDIVIDUAL APPLICANT AND EACH MEMBER OF PARTNERSHIP The undersigned, each for himself, certifies that he is the applicant above named; that he knows the contents of the above application and the statements contained therein and the same are true of his own knowledge. The undersigned certifies that he/she has read the conditions for the permit applied for and agrees to comply with these conditions. _____________________________________ ____________________________________ _____________________________________ ________________________________