APPLICATION FOR A NEW RETAIL ALCOHOLIC BEVERAGE LICENSE
Entity Name:
Primary Phone:
BENEFICIAL INTEREST - Organization
Alternative Phone:
FEIN:
Email:
Fax Number:
Business Address
Street Name:
Street Name:
State:
Zip Code:
City/Town:
Country:
Zip Code:
City/Town: State:
Street Number:
Country:
Mailing Address
Check here if your Mailing Address is the same as your Business Address
Street Number:
Please complete a Beneficial Interest - Organization sheet for all organization(s) who have a direct or indirect beneficial interest,
with or without ownership, in this license.
Example:
ABC Inc. is applying for a liquor license. ABC Inc. is 100% owned by XYZ Inc., which is 100% owned by 123 Inc. XYZ Inc. is
considered to have a direct beneficial interest in the proposed licensee (ABC Inc.) and 123 Inc. is considered to have indirect
beneficial interest in the proposed licensee (ABC Inc.). Both XYZ Inc. and 123 Inc. should complete a Beneficial Interest -
Organization Form.
Publicly Traded
Is this organization publicly traded?
Yes No
Using the definition above, does this
organization hold a direct or indirect interest in
the proposed licensee?
Direct Indirect
Ownership / Interest
If this organization holds a direct beneficial
interest in the proposed licensee, please list
the % of interest it holds.
If you hold an indirect beneficial interest in this license, please complete the Ownership / Interest Table on the next page.
