Manager Change Application

NORTH CAROLINA ALCOHOLIC BEVERAGE CONTROL COMMISSION Location: 400 E. Tryon Road Raleigh NC 27610 (919)779-0700 APPROVED REJECTED BY: DATE: AMOUNT FEE PAID: DATE: RECEIVED BY: MAIL TO ADDRESS ON BACK OF FORM MANAGER CHANGE APPLICATION (Corporation/LLC) (Do Not Write Above This Line) A certified check, cashier's check or money order in the amount of $10.00 must be submitted with this application. PLEASE PRINT County: (in which event takes place) Date: Corporate Name LLC Name Trade Name of Business Location Address of Business Street Address City State Zip Code Mailing Address of Business Street Address/PO Box City State Zip Code Individual's Full Name (no abbreviations) First Date of Birth Resident Address: Street/Route City State Zip Code Middle Last Last 4 of Social Security # Home Telephone #: ( ) Business Telephone #: ( ) Pleas check the type(s) of ABC permit(s) and include the permit number for each held by the above location. Malt Beverage Fortified Wine Unfortified Wine Other It is a Crime to make a false statement to obtain an ABC permit. I certify under oath or affirmation that I am a resident of the State of North Carolina, or an applicant that has executed a power of attorney in accordance with GS 18B-900(a)(2)(b); that I am not less than 21 years of age; that I have not been convicted of a felony within the past three years, and if convicted of a felony before then, I have had my citizenship restored; that I have not been convicted of an alcoholic beverage or misdemeanor controlled substance offence within the past two years; and that I have not had any alcoholic beverage permit revoked within the past three years. Brownbagging Special Occasions Mixed Beverage Signature of Applicant Sworn to and subscribed before me this the _________day of ____________________, 20__________ My commission expires: Notary or other person qualified by law to administer oaths Note: Must be stamped or sealed by notary. American LegalNet, Inc. www.FormsWorkFlow.com FOR OFFICIAL USE ONLY Do not write below this line INVESTIGATIVE REPORT 1. Have you reviewed the application with the applicant to determine that it is complete and correct? Yes No Does the applicant have any criminal record of disqualifying nature? Yes No 2. If Yes, please explain: 3. Are there any reasons that this individual should not be approved as manager of this location? Yes No If Yes, please explain: Agent's Signature Date MAIL THIS APPLICATION TO: If sending by U.S. Postal Service (regular mail): If sending by U.S. Postal Service EXPRESS MAIL or by FEDEX/UPS: NC ABC COMMISSION 4307 MAIL SERVICE CENTER RALEIGH NC 27699-4307 NC ABC COMMISSION 400 E. TRYON ROAD RALEIGH NC 27610 Corporate Manager Change Application 11/10 American LegalNet, Inc. www.FormsWorkFlow.com