5. Has Applicant or anyone listed on #4 ever held any interest in any other business licensed for the
sale of alcoholic beverages?
□ No □ Yes [If yes, attach explanation - Include Premises Number(s)]
6. Does anyone have any financial interest in the Applicant’s business not previously listed on #4,
including silent partners, private financial loans, etc.? □ No □ Yes [If yes, complete explanation below]
Name: Phone Number:
Address: Ownership interest:
7. List the owner of the building where the premises is located:
(Include a copy of the building lease to the Applicant OR a warranty deed in the Applicant’s name)
8. Premises Diagram/Floor Plan – No architectural blue prints – On paper no larger than 8 ½” x 11”
Attach a sketch showing the entire area proposed to be licensed to sell, serve, dispense, or store alcoholic beverages,
including patios, decks, etc. Diagram must show all entrances, exits, offices, restrooms, kitchen facilities (if
applicable), bar(s), bar backs, liquor cabinets, tables, refrigeration units, partitions, etc. and where license will be
9. Affirmation: The applicant(s) hereby swears or affirms under oath that the applicant is the bona fide owner of the business
which is applying for this license and will be engaged in the sale or dispensing of liquor by the drink, beer and/or wine by the
bottle and/or glass. The applicant(s) hereby affirms that the applicant and/or each person indicated on this application or
attachments thereto is/are eligible and has none of the disqualifications for a license as provided by Title 23, Chapter 9, 10, 11,
12, 13 and 14, Idaho Code, IDAPA 11.05.01 or any amendments thereto.
An application for and acceptance of a license by the applicant(s) shall constitute consent to, and be authority for, entry
by the Director or his authorized agents, upon any premises related to the licensee’s business, or wherein are or should be kept,
any of the licensee’s books, records, ledgers, supplies or other property related to said business, and to make the inventory, check
and investigations aforesaid with relation to said licensee or any other licensee. The application shall also constitute consent given
to the Director, his agents, the sheriff of any county or other law enforcement officer, upon any premises related to the licensee’s
business or wherein are or should be kept, any of the licensee’s books, records, ledgers, supplies or other property related to said
business, and to make the inventory, check and investigations aforesaid with relation to the said licensee or any other licensee.
The application shall also constitute consent given to the Director or his authorized agents to view, copy or investigate any
documents, including state and federal income and sales tax returns and any documents, associated with the person or business
that are exercising the privilege of the license, as per Idaho Code sections 23-907, 23-1006 and 23-1314 and IDAPA 11.05.01.
Applicant(s) hereby acknowledges that falsifying this document or submitting any false documents for record can result in
a felony conviction under Idaho Code sections 23-905 or 18-3203. Applicant(s) further acknowledges that they and/or each person
indicated on this application or attachments understand that state law controlling alcohol beverage licensing is found at Title 23,
Idaho Code (https://legislature.idaho.gov/statutesrules/idstat/title23/
) and the Alcohol Beverage Control administrative rules,
11.05.01 (https://adminrules.idaho.gov/rules/current/11/110501.pdf), and that any violation of these laws or rules can
result in criminal and/or administrative sanctions, and up to and including license revocation.
Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history records of the
FBI. You have the opportunity to complete or challenge the accuracy of the information contained in the FBI identification record.
The procedure for obtaining a change, correction, or updating an FBI identification record are set forth in Title 28, CFR, 16.34.
10. Signature Certification:
I/we, the applicant(s) of this license, acknowledge and understand Idaho Code Title 23 and IDAPA that regulate licenses provided by
the Idaho liquor act and do hereby agree to operate the licensed premises in conformity with these statutes and regulations. I
certify under penalty of perjury pursuant to the law of the state of Idaho that the foregoing is true and correct.
Authorized Agent/Applicant’s Signature Title Date
Authorized Agent/Applicant’s Printed Name
ALCOHOL BEVERAGE CONTROL BUREAU