Fillable Form 2.: OCCUPATIONAL AND BUSINESS LICENSE ALCOHOLIC BEVERAGE (City of New Orleans)

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Form 2.: OCCUPATIONAL AND BUSINESS LICENSE ALCOHOLIC BEVERAGE (City of New Orleans)

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Business
License
1300 PERDIDO ST | SUITE 7W03 | NEW ORLEANS | LOUISIANA | 70112 | 504.658.7100 1
OCCUPATIONAL AND BUSINESS LICENSE ALCOHOLIC BEVERAGE OUTLET PACKET
INSTRUCTIONS
1. COMPLETE THE OCCUPATIONAL AND BUSINESS LICENSE: ALCOHOLIC BEVERAGE OUTLET
APPLICATION
Have you double-checked your application (pages 4-6) to verify that ALL fields are complete, all
questions have been answered and the application is signed and notarized (page 6)?
2.
COLLECT AND ATTACH THE ITEMS LISTED BELOW TO YOUR APPLICATION
3. SUBMIT THE COMPLETED APPLICATION AND ATTACHMENTS
Submit the signed and completed application with the attachments by mail or in person of this
application packet to: Attn: ABO Processing
City of New Orleans, One Stop
1300 Perdido St., 7W03
New Orleans, LA 70112
OVERVIEW OF ITEMS TO SUBMIT WITH APPLICATION
1. Completed and signed appl
ication form
2. Executed copy of your lease, if not owne
r
3. Corporate Documents
4. Proof of tax clearance from City Bureau
of
Revenue
5.
Plot Plan/Layout
6. Colored Copy of photo
ID
7. Application fees
8. Supplement A forms
9. Acknowledgement of Bar or Restaurant Us
e
Stand
a
rds
10.
Schedule F form (if required)
ATTACHMENTS DESCRIBED AND EXPLAINED
1. Completed and signed application form (Pages
4- 6)
2. Executed copy of your lease, if not owne
r
If the applic
ant DOES NOT own the premise to be permitted:
Attach a copy of the signed and dated lease or management agreement.
Note: the lease or management agreement must be between the landowner and
applicant: not an individual member/shareholder/partner, etc.
3. Corporate Documents
The doc
uments required depend on the type of legal entity applying:
If the applicant is a CORPORATION OR LLC:
Attach a copy of the Articles of Incorporation or Articles of Organization (obtained
from th
e Secretary of State) .Ensure that the entity is registered and "in good
standing" with the Secretary of State.
If the applicant is a PARTNERSHIP:
Attach a notarized Partnership Agreement.
If applicant is ANY OTHER LEGAL ENTITY:
Attach a copy of the business' paperwork as filed with the LA Secretary of State.
If the applicant is a SOLE PROPRIETOR (AN INDIVIDUAL):
No corporate documents are required.
4. Proof of tax clearance from City of New Orleans Bureau of
Revenue located on the first floor of City
Hall
at 1300 Perdido St., Rm 1W15, New Orleans, LA
70112.
Business
License
1300 PERDIDO ST | SUITE 7W03 | NEW ORLEANS | LOUISIANA | 70112 | 504.658.7100 2
5.
Plot Plan/Layout
A plot plan/layout of the entire floor area that will be occupied by the proposed business
clearly labeling measurements of all walls of attached and unattached buildings, property
lines, doors, windows, patios, holding bars, stages, tables, seating/chair arrangements, food
preparation areas and equipment, restrooms, amusement devices, emergency exits and
lighting locations, back of house operations, and any other related features.
Note: Diagram must be large enough to be legible, at least 8 ½”' by 11"(letter size).
6.
Colored Copy of photo ID
COLORED copy of Driver's License or government-issued ID
7.
Application fees, in accordance with Chapter 10-122 of the City Code of New Orleans.
NON-REFUNDABLE APPLICATION FEES
Alcoholic beverage outlet application processing fee: $1,000.00
(new applications & renewal of applications)
Manager's annual permit fee: $100.00
An additional $50.00 nonrefundable processing fee must be paid at the time of application if
the business is located in:
o
the Vieux Carré
o
the New Orleans Historic District Landmarks Commission (NO HDLC)
o
the Central Business District Historic District Landmarks Commission (CBD HDLC), or
o
any area of the city that is subject to any moratorium on the issuance of alcoholic
beverage permits at the time of application
Fees are processed immediately upon receipt. If your application is rejected or denied, fees will NOT
be returned or refunded.
PRIOR TO THE ISSUANCE OF THE LICENSE, THE FOLLOWING ADDITIONAL FEES ARE DUE:
If the business is located in Vieux Carré, NO HDLC, CBD HDLC, or a moratorium district at the
time of application, an additional fee of $125.00 must be paid.
RETAIL or WHOLESALE BEER ONLY (low content: 6% and lower by volume) = $135.00
RETAIL or WHOLESALE WINE/LIQUOR (high content: 6% and higher by volume) = $500
FORMS OF PAYMENT ACCEPTED:
IN-PERSON PAYMENT Checks, Cashier’s Checks, Money Orders, Visa, MasterCard, and
Discover. Please make all checks and money orders payable to City of New Orleans.
ONLINE PAYMENT MasterCard, Discover, and Visa. You can pay online by logging in at
onestopapp.nola.gov and searching for this item by application or invoice number.
8.
Supplement A forms for EACH owner, partner or financially interested party, officer, director,
member, manager, and registered, authorized and qualified agent of this business
9.
Acknowledgement of Bar or Restaurant Use Standards
10.
Supplement F form (if required)
A Schedule F form is only required to be submitted by any person completing a Schedule A
form IF either:
o
The person completing the Schedule A has been convicted of a felony; or
o
The spouse of the person completing the Schedule A has been convicted of a felony
NOTE: you must disclose all felony convictions EVEN IF you have received a pardon,
expungement, deferred adjudication, etc.
Attach court documents (disposition) for all Schedule F forms submitted.
Business
License
1300 PERDIDO ST | SUITE 7W03 | NEW ORLEANS | LOUISIANA | 70112 | 504.658.7100 3
INFORMATION ON TYPES OF ESTABLISHMENTS
When deciding which class and type of permit best suits your business model, please refer to Chapter 10 of
the City Code of New Orleans available at https://library.municode.com/la/new_orleans/codes/. Some
helpful information is contained below, but encourages you to refer to the particular state and local laws for
a complete listing of requirements.
CITY OF NEW ORLEANS CLASS A-GENERAL per CCNO Ch. 10-53(1): includes WINE/LIQUOR (high content,
as defined by CCNO Ch. 10-1, 6% and higher by volume) and/or BEER ONLY (low content, as
defined by CCNO Ch. 10-1, 6% and lower by volume), and issued to a retail outlet:
where alcoholic beverages are sold on the premises for consumption on or off the premises
by paying customers
that is equipped with a permanent wet bar equipped with a non-movable sink and backbar or
similar equipment for public display and to inform the public of brands and flavors offered for
sale.
that is staffed by a bartender whose primary duty is to open and/or prepare alcoholic
beverage products for consumption on or off the premises by paying customers, or prepared
with an appropriate lid or cover on the container for takeout service. Such an establishment
must meet all state and city health and zoning requirements as set forth by the state or the
city; and
where city and state law provides that no person under the age of 18 years is allowed on the
premises except as provided by R.S. 26:90(A)(8)(a) and 26:286(A)(8)(a).
CITY OF NEW ORLEANS CLASS A-RESTAURANT per CCNO Ch. 10-53(2): includes WINE/LIQUOR (high
content, as defined by CCNO Ch. 10-1, 6% and higher by volume) and/or BEER ONLY (low
content, as defined by CCNO Ch. 10-1, 6% and lower by volume) and issued to a restaurant:
with a valid Class "R" permit issued by the state.
which operates a place of business whose purpose and primary function is to take orders for
and serve food and food items;
which serves alcoholic beverages in conjunction with meals;
which serves food on all days of operation;
which maintains separate sales figures for alcoholic beverages; and
which operates a fully equipped kitchen used for the preparation of uncooked foods for
service and consumption of such foods on the premises of the establishment; and
which grosses at least 50 percent of its average monthly revenue from the retail sale of food,
food items that are prepared for service and consumption on the premises of the
establishment, and nonalcoholic beverages.
CITY OF NEW ORLEANS CLASS B-GENERAL RETAIL PERMIT per CCNO Ch. 10-54:
includes WINE/LIQUOR
(high content, as defined by CCNO Ch. 10-1, 6% and higher by volume) and/or BEER ONLY (low content, as
defined by CCNO Ch. 10-1, 6% and lower by volume) and permit shall be issued only to an outlet where
alcoholic beverage is sold for CONSUMPTION OFF PREMISES by paying customers.
Business
License
1300 PERDIDO ST | SUITE 7W03 | NEW ORLEANS | LOUISIANA | 70112 | 504.658.7100 4
OCCUPATIONAL AND BUSINESS LICENSE: ALCOHOLIC BEVERAGE OUTLET APPLICATION
BUSINESS INFORMATION
Legal Name of Business
_
________________________________________
_
Date of Application
_
_______________
_
Trade Name of Business
_
________________________________________
_
FEIN
_
___________________________
_
Ownership Type:
Individual
Partnership
Corporation
Limited Liability Company (LLC)
Non-Profit
Business Location Street Address
_
_____________________________________________, New Orleans, LA _______
_
(zip code)
Mailing Street Address
_
_____________________________________________________________________
_
_
____
_
Mailing City ______________________
_
_
__
_
_
___ Mailing State
_
_______
_
_
________ Mailing Zip ____
_
_
___
_
Contact Name
_
______________________________ Contact Phone(s)
_
_______________
_
_
__
_
_
___________
Contact Email
_
______________________________ Relationship to Business ___
_
_
__
_
_
__________________
Preferred Method of Contact _________________________________________________________________________
_
TYPE OF CITY OF NEW ORLEANS LICENSE APPLIED FOR:
Class A General - Retail outlet, consumption ON premises
(bar, lounge, event, etc.)
Class A Restaurant - subject to CCNO Ch.10-53(2)
Class A Restaurant Conditional - subject to CCNO Ch.10-53(2)
Class B General - Retail outlet with consumption OFF premises
(retail store, grocery, etc.)
Wholesale
Other: ____________________________________________________
CONTENT OF ALCOHOL TO BE SOLD:
Low Alcohol (beer)
High Alcohol (wine/liquor)
SALES TYPE:
On premise
Off premise
Reason for Application:
New Business
Purchase of Existing Business
Other Change in Ownership
LOCATION OWNERSHIP INFORMATION
Does the applicant own the premises to be permitted?
Yes
No
If “no”, complete the section below, which is incorporated by the oath sworn on this application.
A copy of this Registration Application and all attachments have been delivered in person to ____________________,
(lessor name)
who resides at ___________________________________________________________ and who is the legal owner of
(lessor legal address)
_________________________________________________ , the premises wherein the affiant named below desires to
(business address associated with this application)
operate the business known as________________________________ as a ________________________________.
(business name) (type of business).
BUSINESS INFORMATION
For EACH owner, partner or financially interested party, officer, director, member, manager, and registered, authorized
and qualified agent of this business please list their title and relationship to the business. All parties listed below must
additionally attach a Supplement A and Supplement F, if required.
Name Relationship to Business
Business
License
1300 PERDIDO ST | SUITE 7W03 | NEW ORLEANS | LOUISIANA | 70112 | 504.658.7100 5
OCCUPATIONAL AND BUSINESS LICENSE: ALCOHOLIC BEVERAGE OUTLET APPLICATION
OPERATIONAL INFORMATION
Will this business be open exclusively to other alcohol retailers? Yes No
Is the purpose and primary function of this business to take orders for and to prepare alcoholic
beverages?
Yes No
Will live performances (e.g. bands, singers, other performers, DJs, etc.) take place at this
establishment?
Yes
No
Will admission be charged for performances at this establishment?
Yes
No
Is the purpose and primary function of this business to take food orders and serve food/food items? Yes No
Will this business serve alcoholic beverages in conjunction with meals? Yes No
Will the average monthly revenue from food and non-alcoholic beverages exceed 50% of its total
average monthly revenue?
Yes No
Will this business maintain separate sales figures for alcoholic beverages? Yes No
Will this business serve food on all days of operation? Yes No
Will this business operate a fully-equipped kitchen used for the preparation of uncooked foods for
service and consumption of such food on the premises?
Yes No
Is this location at least 300 feet from any public playground, public library, place of worship, school,
synagogue or day care center as required by CCNO Ch.10-236(a)?
Yes No
Is all construction and/or remodeling of the premises to be licensed complete?
If "No," provide an estimated completion date: _________________
This application will be denied if construction/remodeling are not fully complete at the time of
inspection.
Yes No
AUTHORIZATION TO SIGN/ACKNOWLEDGMENTS & AFFIDAVIT
All information obtained as a result of your acknowledgement below will be used in all areas of this application process
and any renewals thereof, including the hearings before the Alcoholic Beverage Control Board, or any appeals
therefrom. The below must be signed and sworn to by: If the applicant is an Individual, the same Individual; If the
applicant is a Partnership, each Partner; If the applicant is a Corporation, an Officer/Director; If the applicant is an LLC,
an Officer/Director/Member.
STATE OF LOUISIANA, PARISH OF ORLEANS
Before me, the undersigned Notary Public, personally came and appeared__________________________________,
the appeared(s) in the above and foregoing instrument, who declared under oath to me, Notary,:
that he/she prepared and signs the above and foregoing OCCUPATIONAL AND BUSINESS LICENSE:
ALCOHOLIC BEVERAGE OUTLET APPLICATION including the required attachments, and that the instrument
is tendered in support of the Occupational and Business License Master Application for an alcoholic beverage
permit made to the City of New Orleans by the business applicant stated herein,
that the signature appearing hereon is his/her own, of his/her own free and voluntary act and is for intent and
purposes therein expressed, and that he/she swears that the information given and all answers therein are
true and correct.
that the applicant for this license and its members meet all qualifications and conditions of Chapter 10 of the City
Code of New Orleans;
that the appeared(s) understands that any change in ownership or membership in the business applied for
must be reported immediately to the City of New Orleans;
that pursuant to Chapter 10, Sections 10 and 115 of the City Code of New Orleans any person or any agent or
employee of any person who shall make false oath to any report or application required by the provisions of
this chapter shall be guilty of the crime of false swearing and such an action may constitute a violation of
Sec.10-6(4) “Concealing violations” as basis for revocation of any license or permit obtained pursuant to this
application.
that Chapter 54-401 of the City Code & 492 and the International Building Code as adopted in Chapter 26 of
the Code of the City of New Orleans, restrict the serving of alcoholic beverages on to sidewalk and right of
ways and in any manner that causing the obstruction of the same;
Business
License
1300 PERDIDO ST | SUITE 7W03 | NEW ORLEANS | LOUISIANA | 70112 | 504.658.7100 6
OCCUPATIONAL AND BUSINESS LICENSE: ALCOHOLIC BEVERAGE OUTLET APPLICATION
that any temporary change of use including the temporary addition of bars or counters requires separate and
additional approval pursuant to Chapter 10-52 of the City Code of New Orleans and Section 21.8 of the New
Orleans Comprehensive Zoning Ordinance; and
that any permanent changes to the layout, operating hours, floor space used, security plans, noise production,
or alteration of the business location of a retailer who offers consumption on premises will require that a
revised the Acknowledgement of Bar Use Standards or the Acknowledgement of Restaurant Use Standards
must be submitted to the Department of Safety of Permits for review prior to implementation.
Further, the appeared(s) hereby authorize and acknowledge by signature below, that I authorize the Police
Department and its agents or employees to release to the Department of Safety and Permits, Department of Finance,
Law Department of the City of New Orleans and agents or employees thereof information received as a result of this
application review, including but not limited to, all police reports, arrest records, whether municipal, state, or federal
and any other documentation which make reference to me. I do further agree to relieve, release, and indemnify the
City of New Orleans’ Police Department, Department of Safety and Permits, Department of Finance, Law Department
and all agents or employees thereof from any and all liability as a result of the release of this information.
________________________________________________
Print Name of Applicant
________________________________________________
Applicant Signature
________________________________________________
Print Name of Applicant
________________________________________________
Applicant Signature
Sworn and subscribed before me this day of 20 .
_
______________________________________________
_
Print Name of Notary Public
_
______________________________________________
_
Notary Public Signature
My commission is for________________________________________________
Business
License
1300 PERDIDO ST | SUITE 7W03 | NEW ORLEANS | LOUISIANA | 70112 | 504.658.7100 7
ALCOHOLIC BEVERAGE OUTLET INDIVIDUAL APPLICATION SUPPLEMENT A
This form is required for EACH owner, partner or financially interested party, officer, director, member, manager, and
registered, authorized and qualified agent of this business please list their title and relationship to the business.
BUSINESS INFORMATION
Legal Name of Business
_
________________________________________
_
Date of Application
_
_______________
_
Trade Name of Business
_
________________________________________
_
FEIN
_
___________________________
_
Ownership Type:
Individual
Partnership
Corporation
Limited Liability Company (LLC)
Non-Profit
Business Location Street Address
_
_____________________________________________, New Orleans, LA _______
_
(zip code)
INDIVIDUAL BACKGROUND INFORMATION
Individual Name
_
______________________________
Individual Phone(s)
_
___________________________
Individual Email
_
______________________________ Relationship to Business ______________________
Individual Street Address
__________________________________________________________________________
City ____________________________________ State _____________________ Zip _____________
Preferred Method of Contact _____
_
_
________________
_
Date of Birth
_
__
_
_
_______________________________
_
Occupation
_
_________________________________
Place of Birth _____________________________________
Employer
_
___________________________________
Social Security Number _____________________________
Driver's License Number
_
________________________
State of Issuance
_
______________
Maiden Name/Aliases (if any):
_
________________________
Relationship Status _________________________
If married, please complete the following fields:
Name of Spouse ___________________________ Spouse Maiden Name/Aliases ___________________
Spouse Date of Birth _______________________ Spouse Social Security Number _________________
Spouse Driver's License Number ____________________________ State of Issuance _______________
QUALIFICATIONS
1.
Is the applicant listed also applying for a video poker license issued by Louisiana State Police?
Yes
No
2.
Do you or your spouse own or hold interest in any other business holding a state retail beer
and/or liquor permit?
If you or your spouse is an officer, member, or partner in another entity that maintains a
state alcohol permit, complete the following questions. If there is more than one business,
attach a list disclosing each.
Permit Number ___________________________
Trade Name______________________________
Location ________________________________
Yes
No
Business
License
1300 PERDIDO ST | SUITE 7W03 | NEW ORLEANS | LOUISIANA | 70112 | 504.658.7100 8
ALCOHOLIC BEVERAGE OUTLET INDIVIDUAL APPLICATION SUPPLEMENT A
3.
Do you or your spouse own or hold interest in any business holding an alcoholic beverage
manufacturer/supplier permit?
If YES, complete the following questions. If there is more than one business, attach a list
disclosing each.
Permit Number ___________________________
Trade Name______________________________
Location ________________________________
Yes
No
4.
Do you or your spouse own or hold interest in any business holding an alcoholic beverage
wholesale permit or solicitors permit?
If YES, complete the following questions. If there is more than one business, attach a list
disclosing each.
Permit Number ___________________________
Trade Name______________________________
Location ________________________________
Yes
No
5.
Is this application being submitted by you to obtain an alcoholic beverage permit in your name
for the benefit of any other person?
Yes
No
IF YOU ANSWER "YES" TO ANY OF THE FOLLOWING QUESTIONS ABOUT YOUR CRIMINAL
HISTORY, YOU (AND YOUR SPOUSE) MUST COMPLETE A SUPPLEMENT F
6.
Have you or your spouse ever been convicted of violating any state or local alcoholic beverage
regulatory statute, rule, or ordinance?
Yes
No
7.
Have you or your spouse had a license or permit to sell or deal in alcoholic beverages revoked
within the last (2) years prior to the filing of this Schedule A?
Yes
No
8.
Have you or your spouse ever been denied an alcoholic beverage permit?
Yes
No
9.
Have you or your spouse ever been convicted of a felony?
10.
(This includes an offense adjudicated under Article 893 or 894, dismissals, pardons,
expungements, guilty pleas, and pleas of nolo contendere "no contest.")
Yes
No
11.
Have you or your spouse ever been convicted of solicitation for prostitution, pandering, letting
premises for prostitution, contributing to the delinquency of a juvenile, keeping a disorderly
place, or dealing in controlled dangerous substances?
Yes
No
12.
Have you or your spouse ever been convicted of distributing or possessing with intent to
distribute any controlled dangerous substance classified in Schedule I of R.S.40:964 on any
premises holding an alcoholic beverage permit where you held or hold an ownership interest in
the Have you or your spouse been convicted or had a judgment of court rendered against you
involving the sale or service of alcoholic beverages by this or any other state, or by the U.S.
within the last (2) years?
Yes
No
13.
Have you or your spouse ever been convicted, in this or in any other state in the U.S., of theft?
Yes
No
14.
Have you or your spouse ever been convicted, in this or in any other state in the U.S., of any
crime involving false statements or declarations?
Yes
No
ACKNOWLEDGEMENT & AFFIDAVIT
STATE OF LOUISIANA, PARISH OF ORLEANS
Before me, the undersigned Notary Public, personally came and appeared__________________________________,
the appeared(s) in the above and foregoing instrument, who declared under oath to me, Notary,:
that he/she prepared and signs the above and foregoing Supplement A including the required attachments,
and that the instrument is tendered in support of the Occupational and Business License Master Application
for an alcoholic beverage permit made to the City of New Orleans by the business applicant stated herein,
that the signature appearing hereon is his/her own, of his/her own free and voluntary act and is for intent and
purposes therein expressed, and that he/she swears that the information given and all answers therein are
true and correct.
Business
License
1300 PERDIDO ST | SUITE 7W03 | NEW ORLEANS | LOUISIANA | 70112 | 504.658.7100 9
ALCOHOLIC BEVERAGE OUTLET INDIVIDUAL APPLICATION SUPPLEMENT A
that the applicant for this license and his/her spouse, if applicable, meets all qualifications and conditions of Chapter
10 of the City Code of New Orleans;
that pursuant to Chapter 10, Sections 10 and 115 of the City Code of New Orleans any person or any agent or
employee of any person who shall make false oath to any report or application required by the provisions of
this chapter shall be guilty of the crime of false swearing and such an action may constitute a violation of
Sec.10-6(4) “Concealing violations” as basis for revocation of any license or permit obtained pursuant to this
application.
that Chapter 54-401 of the City Code & 492 and the International Building Code as adopted in Chapter 26 of
the Code of the City of New Orleans, restrict the serving of alcoholic beverages on to sidewalk and right of
ways and in any manner that causing the obstruction of the same;
Further, the appeared(s) hereby authorize and acknowledge by signature below, that I authorize the Police
Department and its agents or employees to release to the Department of Safety and Permits, Department of Finance,
Law Department of the City of New Orleans and agents or employees thereof information received as a result of this
application review, including but not limited to, all police reports, arrest records, whether municipal, state, or federal
and any other documentation which make reference to me. I do further agree to relieve, release, and indemnify the
City of New Orleans’ Police Department, Department of Safety and Permits, Department of Finance, Law Department
and all agents or employees thereof from any and all liability as a result of the release of this information.
________________________________________________
Print Name of Applicant
________________________________________________
Applicant Signature
________________________________________________
Print Name of Applicant
________________________________________________
Applicant Signature
Sworn and subscribed before me this day of 20 .
_
______________________________________________
_
Print Name of Notary Public
_
_________
_
_
___________________________________
_
Notary Public Signature
My commission is for________________________________________________
Business
License
1300 PERDIDO ST | SUITE 7W03 | NEW ORLEANS | LOUISIANA | 70112 | 504.658.7100 10
ALCOHOLIC BEVERAGE OUTLET INDIVIDUAL SUPPLEMENT F
This form must be completed by any applicant who has been convicted of a felony or of a misdemeanor and
seeks lawful issuance of an alcoholic beverage permit under the provisions of CCNO Chapter 10-118, R.S.
26:80(f) and/or 26:280(f). Applicant attests that the felony was not a crime of moral turpitude or of
violence as defined in LA R.S. 14:28, and that 5 years or more have passed between the date of this
application and the successful completion of any sentence, deferred adjudication, or period of probation,
parole, and the final discharge of the defendant. Applicant is required to submit official documentation of
pardon, restoration of rights, or official certification that 5 years or more has passed since successful
completion of any sentence, deferred adjudication, or period of probation or parole and the final discharge
of the defendant at the time of application.
BUSINESS INFORMATION
Legal Name of Business
_
________________________________________
_
Date of Application
_
_______________
_
Trade Name of Business
_
________________________________________
_
FEIN
_
___________________________
_
Ownership Type:
Individual
Partnership
Corporation
Limited Liability Company (LLC)
Non-Profit
Business Location Street Address
_
_____________________________________________, New Orleans, LA _______
_
(zip code)
INDIVIDUAL BACKGROUND INFORMATION
Individual Name
_
______________________________
Individual Phone(s)
_
___________________________
Individual Email
_
______________________________ Relationship to Business _______________________
Individual Street Address
__________________________________________________________________________
City ______________________ State _______________ Zip _________
Preferred Method of Contact _____
_
_
________________
_
Date of Birth
_
__
_
_
_______________________________
_
Occupation
_
_________________________________
Place of Birth _____________________________________
Employer
_
___________________________________
Social Security Number _____________________________
Driver's License Number
_
________________________
State of Issuance
_
______________
Maiden Name/Aliases (if any):
_
________________________
CRIMINAL HISTORY INFORMATION
YOU MUST ATTACH A COURT RECORD OF THE DISPOSITION OF EACH CHARGE/CONVICTION
1.
Charge and Statute Number __________________ Date of Conviction ____________________________
Date of Final Discharge _____________________ Jurisdiction (Court/Agency) _____________________
2.
Charge and Statute Number __________________ Date of Conviction ____________________________
Date of Final Discharge _____________________ Jurisdiction (Court/Agency) _____________________
Business
License
1300 PERDIDO ST | SUITE 7W03 | NEW ORLEANS | LOUISIANA | 70112 | 504.658.7100 11
ALCOHOLIC BEVERAGE OUTLET INDIVIDUAL SUPPLEMENT F
ACKNOWLEDGEMENT & AFFIDAVIT
STATE OF LOUISIANA, PARISH OF ORLEANS
I affirm that the above information is true and correct to the best of my knowledge, and that a copy of official
documentation regarding the disposition of each charge/violation is attached.
________________________________________________
Print Name of Applicant
________________________________________________
Applicant Signature
________________________________________________
Print Name of Applicant
________________________________________________
Applicant Signature
Sworn and subscribed before me this day of 20 .
_
______________________________________________
_
Print Name of Notary Public
_
______________________________________________
_
Notary Public Signature
My commission is for________________________________________________
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Form 2.: OCCUPATIONAL AND BUSINESS LICENSE ALCOHOLIC BEVERAGE (City of New Orleans)

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Completed 14 July 2020

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