MIXED BEVERAGE LICENSE APPLICATION CHECKLIST Form-Mixed Beverage Application... · MIXED BEVERAGE...
Transcript of MIXED BEVERAGE LICENSE APPLICATION CHECKLIST Form-Mixed Beverage Application... · MIXED BEVERAGE...
ALCOHOLIC BEVERAGE LAWSENFORCEMENT COMMISSION
3812 N. Santa Fe, Suite 200Oklahoma City, OK 73118
(405) 521-3484
MIXED BEVERAGE LICENSE APPLICATION CHECKLISTBefore completing the application packet read the information below:
•Thebuildinglocationmustbecompletelyconstructedorwithin60daysofcompletionofconstruction inordertoapplyforalicense.
•Both the application pages and additional items required must all be completed and provided forfilingortheapplicationwillnotbeaccepted(onlyexception;thecertificateofcompliance can be provided prior to license issuance).
•Theapplicationwillbereviewedandunderinvestigationuponfilingofapplication.
•The license fee is due upon filing the application.We accept cash, credit card, business check, moneyorder,orcashier’scheckforwalk-incustomers.Mail-incustomerscansubmitthelicensefee bymoneyorder,cashier’scheck,orbusinesscheckonly.
•File the completed application in personor bymail at theABLECommission, 3812N.SantaFe Avenue,Suite200,OklahomaCity,OK73118,MondaythruFriday7:30amto4:30pm.
•ContacttheABLECommissionofficeat(405)521-3484orvisitourwebsiteatwww.able.ok.govfor questionsorgeneralinformation.
Additional items an individual sole proprietor must provide:•ACertificateofLiabilityInsuranceshowingcoverageforbothbodilyinjuryandpropertydamage.
•Adeed,lease,managementagreement,orsalescontractintheindividual’sname.
•ACertificateofCompliancefromthecityorcountywherethebusinessislocatedstatingallbuilding codesforzoning,fire,safety,andhealthareincomplianceorarenotrequired.
•ATaxStatement fromtheCountyTreasurer’sofficestatingnorealorpersonalproperty taxesare owedfortheindividual.
ADDITIONAL ITEMS FOR CORPORATIONS, LIMITED LIABILITY COMPANIES, PARTNERSHIPS AND TRIBES OR TRIBAL CORPORATIONS ARE LISTED UNDER THEIR
RESPECTIVE SECTIONS IN THE FOLLOWING APPLICATION.
Page1ABLE Form #MXB-1 Revised 03/18
BUSINESS OWNERSHIP INFORMATION
ALCOHOLIC BEVERAGE LAWSENFORCEMENT COMMISSION
3812 N. Santa Fe, Suite 200Oklahoma City, OK 73118
(405) 521-3484
MIXED BEVERAGE LICENSE APPLICATIONPleasecompletetheentireform.NolicenseswillbeissuedunlesstheABLECommissionisabletoverifytheinformationprovided.TheABLECommissionmayrequestadditionalinformationnotrequestedonthisapplication.Additionalinformationmayberequiredpriortotheissuanceofanylicense.
MIXED BEVERAGE LICENSES AND FEES
2. DBA Name of Location
3. Location Address
4. Mailing Address
City
5. Business Phone Number 6. Alternate Phone Number 7. E-mail Address
City
County
County
State
State
Zip
Zip
MixedBeverageLicense-$1530
1.PrimaryBusinessatthisLocation
cRestaurant cBar/Club cMotionPictureTheater cEventCenter
cCasino cEntertainmentVenue cGolf&CountryClub cOther_________________________
8. TypeofOwner
cIndividual cPartnership cLimitedPartnership cGeneralPartnership cCorporation
cLimitedLiabilityCompany cTribe cTribalCorporation/Entity cOther__________________________
9a. NameofIndividual/SoleProprietor(ifownedbyanindividual) 9b. SocialSecurityNumber
10b.FederalEmployerIdentification#10a.NameofBusinessEntity(ifPartnership,Corp.,LLCorTribe)
Page2ABLE Form #MXB-1 Revised 03/18
BUSINESS OWNERSHIP INFORMATION
12. Application Contact Person
Application Contact Address
Application Contact Phone Number Application Contact E-Mail Address
13. Name of General Manager Onsite General Manager Phone Number
11.WasPremisesPreviouslyLicensedbytheCommission
cYes cNo
If Yes, to Whom? TypeofLicense
15a.Wheredidyourfundingforthisbusinessoriginate?Check and list all that apply.
INVESTMENT TYPE AMOUNT INVESTMENT TYPE AMOUNT
cOngoingBusinessFunds $ cCash/PersonalFunds $
cPromissoryNote $ cServices $
cLoan $ cEquipment $
cGift $ cOperatingCapital $
cOther $
14.Isyourbusinesslocatedwithin300feetofachurchorpublicschool?
cYes cNo
I,_________________________________,beingdulyswornuponoathdeposesandsays:Thathe/sheistheapplicantwhomakestheaboveandforegoingapplication,thathe/shehasreadandsignedthesame;knowsthecontentsthereofandthatallstatementsthereincontainedaretrue.Applicant(s)certifiesthatthestatementsandrepresentationsmadehereinaretrueandcorrectandconsentsthatifanystatementsandrepresentationshereinarefoundtobefalseoromitted,thattheDirectormayrefusetoissuesaidlicenseormaycausesuchlicensetoberevokedforthwithatanytime.He/Shefurtheragreesthathe/shehasfiledallappropriatepropertywiththeCountyAssessorandthatalladvaloremtaxesassessedonhis/herproperty,bothrealandpersonal,andwhereversituated in thestateofOklahoma,havebeenpaid.
_________________________________________________ SignatureofApplicant(s)
15b.Whomorwheredidtheinitialinvestmentcomefrom?ex. Bank, family owned operation, line of credit, investment type, etc.
Page3ABLE Form #MXB-1 Revised 03/18
CORPORATE OWNERSHIP INFORMATION
CORPORATION / NON PROFIT ORGANIZATIONCorporationsmustcompletethissectionandprovidethefollowingitems:
•ACertificateofGoodStandingfromtheOklahomaSecretaryofState.Contact(405)521-4211
•ACertificateofIncorporationfromtheSecretaryofState.
•AcopyofMinutesElectingCorporateOfficers,Directors,Stockholders,andapplyingfora license withABLE.
•ACertificateofLiabilityInsuranceshowingcoverageforbothbodilyinjuryandpropertydamage.
•Adeed,lease,managementagreement,orsalescontractinthenameoftheCorporation.
•ACertificateofCompliancefromthecityorcountywherethebusinessislocatedstatingallbuilding codesforzoning,fire,safety,andhealthareincomplianceornotrequired.
•ATaxStatement fromtheCountyTreasurer’sofficestatingnorealorpersonalproperty taxesare owedfortheCorporation.
•Notforprofit&501(c)(3)organizationsareonlyrequiredtolistOfficers,notDirectorsorStockholders.
•OnlyStockholdersowning15%ormorearerequiredtobereportedforCorporations.
SSNorFEI#
SSNorFEI#
SSNorFEI#
Drivers License No./State
Drivers License No./State
Drivers License No./State
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
No. of Shares
No. of Shares
No. of Shares
cOfficer cDirectorcStockholder cTrustee/Beneficiary
cOfficer cDirectorcStockholder cTrustee/Beneficiary
cOfficer cDirectorcStockholder cTrustee/Beneficiary
Title
Title
Title
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
1.FederalEmployerIdentificationNumber
2.BusinessEntityName
3. No. of Shares Authorized to Issue No. of Shares Issued No. of Shares Unissued
4. Service Agent Service Agent Address
Page4ABLE Form #MXB-1 Revised 03/18
CORPORATE OWNERSHIP INFORMATION (continued)
SSNorFEI#
SSNorFEI#
SSNorFEI#
SSNorFEI#
SSNorFEI#
SSNorFEI#
SSNorFEI#
Drivers License No./State
Drivers License No./State
Drivers License No./State
Drivers License No./State
Drivers License No./State
Drivers License No./State
Drivers License No./State
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
No. of Shares
No. of Shares
No. of Shares
No. of Shares
No. of Shares
No. of Shares
No. of Shares
cOfficer cDirectorcStockholder cTrustee/Beneficiary
cOfficer cDirectorcStockholder cTrustee/Beneficiary
cOfficer cDirectorcStockholder cTrustee/Beneficiary
cOfficer cDirectorcStockholder cTrustee/Beneficiary
cOfficer cDirectorcStockholder cTrustee/Beneficiary
cOfficer cDirectorcStockholder cTrustee/Beneficiary
cOfficer cDirectorcStockholder cTrustee/Beneficiary
Title
Title
Title
Title
Title
Title
Title
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
IF YOU NEED MORE SPACE USE ADDITIONAL COPIES OF THIS PAGE
Page5ABLE Form #MXB-1 Revised 03/18
LIMITED LIABILITY COMPANY OWNERSHIP INFORMATION
LIMITED LIABILITY COMPANY
1.FederalEmployerIdentificationNumber
2.BusinessEntityName
SSNorFEI#
SSNorFEI#
SSNorFEI#
Drivers License No./State
Drivers License No./State
Drivers License No./State
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
% Membership or Units
% Membership or Units
% Membership or Units
cManagercMember
cManagercMember
cManagercMember
Title
Title
Title
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
3. No. of Memberships or Units Issued 4. Member Managed or Manager Managed
cMemberManaged cManagerManaged
5. Resident Agent Name
Resident Agent Address
LimitedLiabilityCompaniesmustcompletethissectionandprovidethefollowingitems:
•ACertificateofGoodStandingfromtheOklahomaSecretaryofState.Contact(405)521-4211
•AcopyoftheArticlesofOrganizationfiledwiththeSecretaryofState.
•A copy of LLCOperatingAgreement including the schedule or attachment showingmembership interest.
•ACertificateofLiabilityInsuranceshowingcoverageforbothbodilyinjuryandpropertydamage.
•Adeed,lease,managementagreement,orsalescontractinthenameoftheLLC.
•ACertificateofCompliancefromthecityorcountywherethebusinessislocatedstatingallbuilding codesforzoning,fire,safety,andhealthareincomplianceornotrequired.
•ATaxStatement fromtheCountyTreasurer’sofficestatingnorealorpersonalproperty taxesare owedfortheLLC.
Page6ABLE Form #MXB-1 Revised 03/18
LIMITED LIABILITY COMPANY OWNERSHIP INFORMATION (continued)
IF YOU NEED MORE SPACE USE ADDITIONAL COPIES OF THIS PAGE
SSNorFEI#
SSNorFEI#
SSNorFEI#
SSNorFEI#
SSNorFEI#
SSNorFEI#
SSNorFEI#
Drivers License No./State
Drivers License No./State
Drivers License No./State
Drivers License No./State
Drivers License No./State
Drivers License No./State
Drivers License No./State
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
% Membership or Units
% Membership or Units
% Membership or Units
% Membership or Units
% Membership or Units
% Membership or Units
% Membership or Units
cManagercMember
cManagercMember
cManagercMember
cManagercMember
cManagercMember
cManagercMember
cManagercMember
Title
Title
Title
Title
Title
Title
Title
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
Page7ABLE Form #MXB-1 Revised 03/18
PARTNERSHIP INFORMATION
PARTNERSHIP
1.FederalEmployerIdentificationNumber
2.BusinessEntityName
3. Service Agent Service Agent Address
SSNorFEIN#
SSNorFEI#
SSNorFEI#
SSNorFEI#
Drivers License No./State
Drivers License No./State
Drivers License No./State
Drivers License No./State
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
% of Interest
% of Interest
% of Interest
% of Interest
cGeneralPartnercLimitedPartner
cGeneralPartnercLimitedPartner
cGeneralPartnercLimitedPartner
cGeneralPartnercLimitedPartner
Title
Title
Title
Title
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
Partnerships, Limited Partnerships or General Partnerships must complete this section and providethefollowingitems:
•ACertificateofPartnershipfromtheOklahomaSecretaryofState.Contact(405)521-4211
•AcopyofthePartnershipAgreementlistingallpartnersandtheamountofinteresteachpartnerowns.
•ACertificateofLiabilityInsuranceshowingcoverageforbothbodilyinjuryandpropertydamage.
•Adeed,lease,managementagreement,orsalescontractinthenameofthePartnership.
•ACertificateofCompliancefromthecityorcountywherethebusinessislocatedstatingallbuilding codesforzoning,fire,safety,andhealthareincomplianceornotrequired.
•ATaxStatement fromtheCountyTreasurer’sofficestatingnorealorpersonalproperty taxesare owedforeachpartner.
Page8ABLE Form #MXB-1 Revised 03/18
PARTNERSHIP INFORMATION (continued)
SSNorFEI#
SSNorFEI#
SSNorFEI#
SSNorFEI#
SSNorFEI#
SSNorFEIN#
SSNorFEI#
Drivers License No./State
Drivers License No./State
Drivers License No./State
Drivers License No./State
Drivers License No./State
Drivers License No./State
Drivers License No./State
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
Birthdate(mm/dd/yyyy)
% of Interest
% of Interest
% of Interest
% of Interest
% of Interest
% of Interest
% of Interest
cGeneralPartnercLimitedPartner
cGeneralPartnercLimitedPartner
cGeneralPartnercLimitedPartner
cGeneralPartnercLimitedPartner
cGeneralPartnercLimitedPartner
cGeneralPartnercLimitedPartner
cGeneralPartnercLimitedPartner
Title
Title
Title
Title
Title
Title
Title
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
Last NameFirstNameorEntityName MI
IF YOU NEED MORE SPACE USE ADDITIONAL COPIES OF THIS PAGE
Page9ABLE Form #MXB-1 Revised 03/18
TRIBE/TRIBAL OWNERSHIP INFORMATION
TRIBE/TRIBAL CORPORATION
1.FederalEmployerIdentificationNumber
2.NameofTribeorTribalEntity
3. Service Agent Service Agent Address
SSNorFEI# Drivers License No./State Birthdate(mm/dd/yyyy)
cTribalCommitteeOfficer
TitleLast NameFirstNameorEntityName MI
SSNorFEI# Drivers License No./State Birthdate(mm/dd/yyyy)
cTribalCommitteeOfficer
TitleLast NameFirstNameorEntityName MI
SSNorFEI# Drivers License No./State Birthdate(mm/dd/yyyy)
cTribalCommitteeOfficer
TitleLast NameFirstNameorEntityName MI
SSNorFEI# Drivers License No./State Birthdate(mm/dd/yyyy)
cTribalCommitteeOfficer
TitleLast NameFirstNameorEntityName MI
Tribes or Tribal Corporations must complete this sectionandprovidethefollowingitems:
•YoumustsubmitacopyofanyexecutedManagementAgreements.
•YoumustsubmitacopyofthetrustdocumentordeedforthepropertyfortheTribeorCorportation.
•Youmustsubmitaletterfromthetribestatingwhetherofnottheyrequirebuildingcodeinspections orstatingthelocationmeetszoning,fire,safety,andhealthcodes.
•Youmustsubmitaletterfromthetribestatingallrealandpersonalpropertytaxeshavebeenpaidor theirtaxstatusistax-exempt.
•YoumustsubmitaletterfromtheIntertribalCommissionapprovingthetribalgamingcompact.
•YoumustsubmitacopyofasignedandcompletedTribalGamingCompact.
•Youmust submit a copy of the tribal rules, regulations, laws, or ordinances related to alcoholic beverages.
Page10ABLE Form #MXB-1 Revised 03/18
TRIBE/TRIBAL OWNERSHIP INFORMATION (continued)
IF YOU NEED MORE SPACE USE ADDITIONAL COPIES OF THIS PAGE
SSNorFEI# Drivers License No./State Birthdate(mm/dd/yyyy)
cTribalCommitteeOfficer
TitleLast NameFirstNameorEntityName MI
SSNorFEI# Drivers License No./State Birthdate(mm/dd/yyyy)
cTribalCommitteeOfficer
TitleLast NameFirstNameorEntityName MI
SSNorFEI# Drivers License No./State Birthdate(mm/dd/yyyy)
cTribalCommitteeOfficer
TitleLast NameFirstNameorEntityName MI
SSNorFEI# Drivers License No./State Birthdate(mm/dd/yyyy)
cTribalCommitteeOfficer
TitleLast NameFirstNameorEntityName MI
SSNorFEI# Drivers License No./State Birthdate(mm/dd/yyyy)
cTribalCommitteeOfficer
TitleLast NameFirstNameorEntityName MI
SSNorFEI# Drivers License No./State Birthdate(mm/dd/yyyy)
cTribalCommitteeOfficer
TitleLast NameFirstNameorEntityName MI
SSNorFEI# Drivers License No./State Birthdate(mm/dd/yyyy)
cTribalCommitteeOfficer
TitleLast NameFirstNameorEntityName MI
Page11ABLE Form #MXB-1 Revised 03/18
RESIDENTIAL ADDRESS
RESIDENT STATUS
APPLICANT
5.SocialSecurityNumber 6. Drivers License No. / State 7.PlaceofBirth(City,State,Country)
8.Sex 9. Height 10. Weight 12.EyeColor11. Hair Color
13. Home Phone 14. Business Phone
15. Email Address
16.Listresidentialaddressesforthepast(5)yearsstartingwiththecurrentaddress.Attachaseparatesheet ifnecessary.
17a.AreyouaU.S.Citizen?
cYes cNo
17c. If “Naturalized” provide the “A” number? 17d.If“NO”whatisyourlegalstatusintheU.S.?
17b.If“Yes”,answerthefollowing
cNativeBorn cNaturalized
4.Birthdate(mm/dd/yyyy)3. Last Name1. First Name 2. MI
NUMBER AND STREET CITY, STATE, ZIP FROM(mm/yyyy) TO(mm/yyyy)
INDIVIDUAL PERSONAL HISTORYMUST BE COMPLETED BY ALL APPLICANTS:
Individuals,partners,corporateofficers,directors,stockholders,LLCmanagers,LLCmembers, tribal members, trustees, etc.
•Pleasecompleteallfieldsandanswerallquestions.
•AnyfalsestatementwilldisqualifyyouandsubjectyoutoprosecutionunderOklahomaStatelaw.
CURRENT EMPLOYMENT18a.NameofEmployer
Title
Employer’sAddress
From(mm/yyyy) To(mm/yyyy)
17e.ProvidealldocumentssuchasVisa,ResidentAlienorEmploymentAuthorizationDocuments
Page12ABLE Form #MXB-1 Revised 03/18
INDIVIDUAL QUESTIONNAIRE
19e.Ifyouhaveanswered“Yes”to19athrough19d,listbelow
OFFENSE DATE CITY/COUNTY STATE DISPOSITION(fine,probation,incarceration)
20.Areyoupresentlyorhaveyoubeenlicensedoremployedintheliquorbusiness?
cYes cNo
LICENSE TYPE LICENSE NUMBER WHEN LOCATION
21.Haveyoueverreceivedawarning,anoticeofviolation,suspension,fineorrevocationasalicensee?
cYes cNo
WHEN LOCATION
22.Haveyoueverbeenrefusedalicensetosell,serveordispensealcoholicbeverages?
cYes cNo
WHEN LOCATION
23.Haveyoueverheldordoyouholdanyfinancialinterestinanyliquorenterprise(manufacturing,importing, wholesaleorretail)?
cYes cNoWHEN LOCATION
19b.Haveyoubeenconvictedofanycrime,violationorinfractionofanylaw?
cYes cNo
19c.Aretherepresentlypendingagainstyouanycriminalcharges?
cYes cNo
19a.Haveyoueverbeenconvictedof,pledguiltytoornolocontendretoafelony?
cYes cNo
19d.Haveyoueverbeenconvictedofaviolationofanystateorfederallawrelatingtoalcoholicbeverages,or forfeitedanybondwhileanysuchchargewaspendingagainstyou?
cYes cNo
24a.Isyourspouseoranyfamilymember(s)workinginanyareaoftheliquorindustry?
cYes cNo
24b.Ifyes,forwhom?
25a.Areyouamemberofanyboardorcommission,oranagentoranemployeeofthestateofOklahomaorany politicalsubdivisionthereof?(County,City,TownorSchoolDistrict)
cYes cNo
25b.Ifyes,explain
Page13ABLE Form #MXB-1 Revised 03/18
INDIVIDUAL QUESTIONNAIRE (continued)
27a.Doesyourinterestresultinexerciseofcontrolover,orparticipationinthemanagementofthe manufactureorwholesaler’sbusinessorbusinessdecisions?
cYes cNo
26a.Doyouindividually,orthelegalentitytobelicensed,haveanyright,title,lien,claimorotherinterest, financialorotherwise,in,uponortothepremises,equipment,businessofanyABLECommissionLicense?
cYes cNo
28a.Areyoualawenforcementofficial,apeaceofficerengaginginlawenforcementactivitiesorapersonwho appointslawenforcementofficials?
cYes cNo
26b.Ifyes,explain
27b.Ifyes,explain
28b.Ifyes,explain
29. AreyouanemployeeoforrelatedtoanymemberoftheABLECommissionortotheDirectororAssistant Directorbyaffinityorconsanguinitywithinthethirddegree?
cYes cNo
30. Areyouajudge,districtattorneyorpublicofficialwhositsinajudicialcapacitywithjurisdictionoverthe OklahomaAlcoholicBeverageControlAct?
cYes cNo
31. AreyouanemployeeoftheOklahomaTaxCommissionengaginginauditing,enforcingorcollectingof alcoholicbeveragetaxes?
cYes cNo
I, _________________________________, under penalty of law, swear that I have read allinformationprovidedinthisdocumentandanyattachmentsandtheinformationistrueandcorrect.Ialsounderstandanyfalsestatementorrepresentationinthisapplicationcanresultinmyapplicationbeingdeniedand/orcriminalchargesbeingfiledagainstme.IalsoauthorizetheABLECommissiontousealllegalmeanstoverifytheinformationprovided.IauthorizeanypersonororganizationlistedinthisapplicationtoprovideinformationaboutmetoanAgentoftheOklahomaAlcoholicBeverageLawEnforcementCommissiononaconfidentialbasis,includingbankandfinancialrecords,criminalhistoryrecords,drivingrecords,taxrecordsandanyotherinformationrelatingtocharacterorfitnessforaliquorlicense.IwillimmediatelynotifytheABLECommissionifaLicensee-Wholesalerconnectionasdescribedinthequestionnaireaboveexistsoriscontemplatedinmybusiness.
_________________________________________________ Signature of Applicant
_________________________________________________ Title
Page14ABLE Form #MXB-1 Revised 03/18
LOCATION DIAGRAMDraworattachadiagramofthelicensedpremises.Thediagramshouldincludethefollowing:outside dimensions, rooms, doorways, bars and liquor storage areas. DO NOT SUBMIT BLUEPRINTS
Page15ABLE Form #MXB-1 Revised 03/18
NOTICE OF INTENTION TO APPLY FOR AN ALCOHOLIC BEVERAGE LICENSE
1. Complete in detail2.Copytonewspaperforpublication3.Saidnoticeshallbepublished innot less than2column inches ina legalnewspaperof generalcirculationinthecountyinwhichlicensedpremisesaretobelocated.4.Thenoticewillbetwicepublished,onceeveryeight(8)daysfortwo(2)successiveweeks.5.Submitoriginalwithapplication.
In accordance with Title 37, Section 522 and Title 37A, Section 2-141
_______________________________________________________________________________
_______________________________________________________________________________
a/an_______________________________________________________________herebypublishes
noticeof__________ intention toapplywithinsixtydays from thisdate to theOklahomaAlcoholic
Beverage Laws Enforcement Commission for a Mixed Beverage License under
authority of and in compliance with the said Act: That _________ intend(s), if granted
such license to operate as a Mixed Beverage establishment with business premises
located at _____________________________________________________________________________
in ___________________, ___________________, Oklahoma under the business name of
__________________________________________________________________________________
Datedthis_________________________dayof_______________________________,20_______
Signature of applicant(s): if partnership, all partners must sign. If corporation, an officerof the corporation must sign. If limited liability company, a manager must sign. If tribe, atribalmembermustsign.
________________________________ ________________________________
________________________________ ________________________________
Countyof___________________,Stateof___________________
Beforeme,theundersignednotarypublic,personallyappeared:
______________________________________________________________________________to me known to be the person(s) described in and who executed the foregoing application and
acknowledgedthat_____________executedthesameas_____________freeactanddeed.
____________________________________________________________
nameandaddressofindividual,partners,limitedpartnership,corporation,limitedliabilitycompany,tribeortribalcorporation
city county
individual,partnership,limitedpartnership,corporation,limitedliabilitycompany,tribeortribalcorporation
his,her,its,their
he,she,it,they
he,she,they
NotaryPublic Mycommissionexpires
his,her,their
Page16ABLE Form #MXB-1 Revised 03/18
I do hereby declare, under penalty of perjury, that ______________________________________
did cause to be published in a legal newspaper of general circulation in the county
of ___________________ located in the city of ______________________,Oklahoma by causing
the same to be published on the _______ day of ____________________, 20________ and on
the _______ day of ____________________, 20________, a notice of intention to apply for an
ABLECommissionLicense,andthatatruecopyofsaidnoticeisattachedandmadeaparthereof.
________________________________________
Subscribedandsworntobeforemethis_______dayof____________________,20______.
____________________________________________________________
1.Attachacopyofeachrunofthepublication.2.Submitoriginalcompletedproofofpublicationwithapplication.3.Youmaysubmitthepublisher’saffidavitforminplaceoftheaboveaffidavit.
Nameoflegalnewspaper
Legalrepresentativeofthenewspaper
PROOF OF PUBLICATION
NotaryPublic Mycommissionexpires