Application For Transfer Of Licenses For Sale Of Fermented Malt Beverages And Or Intoxicating Liquor From One Premises To Another {AT-112}

RETAIL LICENSE TRANSFER ­ PREMISES TO PREMISES Wisconsin Department of Revenue FEE $ APPLICATION FOR TRANSFER OF LICENSES FOR SALE OF FERMENTED MALT BEVERAGES AND/OR INTOXICATING LIQUOR FROM ONE PREMISES TO ANOTHER , Wisconsin , 20 To the governing body of the County of City Village Town of Wisconsin. license from (proposed location) The undersigned hereby applies for a transfer of Class to (present location) on or about (date) . 1. APPLICANT: (print name and address plainly) (a) (b) Full name of applicant Address 2. LOCATION AND DESCRIPTION OF PREMISES TO WHICH APPLICATION FOR TRANSFER IS MADE: Describe building or buildings where alcohol beverages are to be sold, served, consumed, and stored. (a) (b) (c) Street number Trade name of establishment Physical description of building, buildings and/or land area comprising licensed premises. (d) (e) Legal description (omit if street address is given above.) Is any other business conducted on same premises? Yes No If so, what? (f) (g) Was this location licensed for beer or liquor during the past year? Give name and address of previous licensee. Yes No (h) Will the previous licensee surrender its license? Yes No AT-112 (R. 6-14) American LegalNet, Inc. www.FormsWorkFlow.com Wisconsin Department of Revenue ALL APPLICANTS FOR TRANSFER OF CLASS B LICENSES MUST ANSWER THE FOLLOWING: 3. If granted, state any interest, directly or indirectly, that any brewer, bottler, wholesaler, manufacturer, or rectifier will hold in the premises for which you are applying If you do not own the fixtures, state the manner, terms and conditions under which said fixtures are held 4. (Signature) State of Wisconsin County of } ss. (I) (We), and being first duly sworn on oath says that (he/she is) (they are) the person(s) above named and that the answers to the questions in each instance are complete and true. Subscribed and sworn to before me this day of , 20 Notary Public, My Commission Expires County, Wis. CLASS OF BUSINESS Submitted to Council or Board Date Approved Treasurer's Receipt No. Proposed Location Original Location License No. Denied Name Ward Ward Filed Date American LegalNet, Inc. www.FormsWorkFlow.com