Special Use Permit Scientific And Educational Application

UTAH DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL 1625 South 900 West PO Box 30408 Salt Lake City, Utah 84130-0408 (801) 977-6800 Fax 977-6888 www.abc.utah.gov SPECIAL USE PERMIT (SCIENTIFIC & EDUCATIONAL) APPLICATION CHECKLIST Dear Applicant: The items below must be completed and submitted by the 10th of the month before any action can be taken by the Utah Alcoholic Beverage Control Commission. You will be notified of the next monthly commission meeting at which your application will be considered for issuance of a license. 1. 2. 3. Completed application (form enclosed). Criminal history background check information (see application). Local Consent from either city/town council if premises in incorporated area, or county commission if unincorporated area (form enclosed). 4. $125.00 initial fee (refundable if permit not granted). Make check payable to Utah Department of Alcoholic Beverage Control. Enclosed for your information are copies of the Utah Code and the Utah Department of Alcoholic Beverage Control Rules pertaining to Special Use permits. If you have any questions, please contact Licensing and Compliance at (801) 977-6800. Effective 7.1.11 v.7.18 page 1 of 15 American LegalNet, Inc. www.FormsWorkFlow.com UTAH DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL APPLICATION FOR SPECIAL USE PERMIT (Scientific & Educational) 1. Applicant/Organization: ____________________________________________________ 2. Business Name: ___________________________________________________________ 3. Location: _________________________________________________________________________ Street City State Zip 4. Mailing Address:___________________________________________________________________ Street P O Box City State Zip 5. Business phone: __________________ Other phone:__________________ Fax: _________________ 6. Contact person: _____________________________ E-mail: _______________________ 7. Ownership: Check appropriate box and provide the requested information in the space below. (add additional sheets if necessary) [] [] [] Applicant is an individual: List below information for: (a) Individual (a) All Partners (a) Any Stockholder owning at least 20% of the corporation (b) All Corporate officers and Directors (a) Any members owning at least 20% of the company Applicant is a partnership: List below information for: Applicant is a corporation: List below information for: [] Applicant is a limited liability company (LLC): List below information for: TITLE____________NAME_______________________HOME ADDRESS_________________________________ HOME PHONE#______________DR LIC#_____________SS#______________DOB__________%OWNED_____ Are you a United States Citizen? ________ If no, must attach a copy of residency status. TITLE____________NAME_______________________HOME ADDRESS_________________________________ HOME PHONE#______________DR LIC#_____________SS#______________DOB__________%OWNED_____ Are you a United States Citizen? ________ If no, must attach a copy of residency status. TITLE____________NAME_______________________HOME ADDRESS_________________________________ HOME PHONE#______________DR LIC#_____________SS#______________DOB__________%OWNED_____ Are you a United States Citizen? ________ If no, must attach a copy of residency status. Effective 7.1.11 v.7.18 page 2 of 15 American LegalNet, Inc. www.FormsWorkFlow.com 8. Criminal History. The law prohibits persons who have been convicted of certain crimes from being in the alcoholic beverage business. This applies to any applicant, proprietor, partner, managing agent, director, or officer of the business. This also applies to any stockholder owning at least 20% of the corporation stock, or if a limited liability company, any member owning at least 20% of the company. Please list all criminal offenses other than minor traffic offenses of which you or any of these persons (including persons listed in subparagraph 5) have ever been convicted. NAME CRIMINAL OFFENSE DATE OF CONVICTION In addition, a criminal history background check must be furnished on each person listed above and in subparagraph 5. This may be done as follows: a. Utah residents: If any person listed has been a resident of Utah for at least two years, he/she shall submit a fingerprint card to the DABC and consent to a fingerprint criminal background check by the Utah Bureau of Criminal Identification. b. Non Residents: Out of state residents or persons who have resided in Utah for less than two years shall submit a fingerprint card to the DABC and consent to a fingerprint criminal background check by the Federal Bureau of Investigation (F.B.I). An informed consent and release of liability form is included with this application. Fingerprint cards are available at law enforcement agencies. You may download the fingerprint card at this web address: http://www.fbi.gov/hq/cjisd/pdf/fpcardb.pdf Submit the form(s) to the DABC with a processing fee of: · $20.00 per card for BCI background checks, or · $39.25 per card for FBI background checks. In the case of an undue delay in the processing of an F.B.I. or B.C.I. criminal background check, here are the rules and procedures for obtaining a third-party national background check: An application that requires a criminal history background report(s) may be included on a commission meeting agenda, and may be considered by the commission for issuance of a license, permit, or package agency if: 1). the applicant has completed all requirements to apply for the license, permit, or package agency other than the department receiving the criminal history background report(s); 2). the applicant attests in writing that he or she is not aware of any criminal conviction of any person identified in the application that would disqualify the applicant from applying for and holding the license, permit, or package agency; 3). the applicant has submitted to the DABC the necessary fingerprint card(s) required for the application and consented to the fingerprint criminal background check(s). 4). the applicant at the time of application supplies the department with a current criminal history background report conducted by a third-party background check reporting service on any person for which a background check is required; and 5). the applicant stipulates in writing that if a B.C.I. or F.B.I. report shows a criminal conviction that would disqualify the applicant from holding the license, permit, or package agency, the applicant shall immediately surrender the license, permit, or