Fillable Form ABC-211-SIG APPLICATION SIGNATURE SHEET

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Form ABC-211-SIG APPLICATION SIGNATURE SHEET

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  • 22 check-boxes
  • 44 other fields

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State of California Department of Alcoholic Beverage Control
APPLICATION SIGNATURE SHEET ("SIGN ON")
• Read instructions on reverse before completing.
• All signatures must be witnessed by an ABC
employee or notarized in accordance with laws
of the State where signed.
1. OWNERSHIP TYPE (Check one)
Sole Owner
Partnership
Married Couple
Domestic Partner
Partnership-Ltd
Corporation
Limited Liability Company
Other
2. FILE NUMBER (If any) 3. LICENSE TYPE 4. TRANSACTION TYPE
Original
Exchange
Person to Person Transfer
Premise to Premise Transfer
Other
5. APPLICANT(S) NAME (Last, first, middle)
6. APPLICANT'S MAILING ADDRESS (Street address/P.O. box, city, state, zip code)
7. PREMISES ADDRESS (Street address, city, zip code)
APPLICANT'S CERTIFICATION
Under penalty of perjury, each person whose signature appears
below, certifies and says: (1) He/She is an applicant, or one of the
applicants, or an executive officer of the applicant corporation,
named in the foregoing application, duly authorized to make this
application on its behalf; (2) that he/she has read the foregoing and
knows the contents thereof and that each of the above statements
therein made are true; (3) that no person other than the applicant or
applicants has any direct or indirect interest in the applicant or
applicant's business to be conducted under the license(s) for which
this application is made; (4) that the transfer application or proposed
transfer is not made to (a) satisfy the payment of a loan or to fulfill an
agreement entered into more than ninety (90) days preceding the day on
which the transfer application is filed with the Department, (b) to gain
or establish a preference to or for any creditor or transferor, or (c ) to
defraud or injure any creditor or transferor; (5) that the transfer
application may be withdrawn by either the applicant or the licensee
with no resulting liability to the Department.
I understand that if I fail to qualify for the license or withdraw this
application, the application fee shall be non-refundable as specified in
Section 23320 B&P.
SOLE OWNER
8. PRINTED NAME (Last, first, middle) SIGNATURE
X
DATE SIGNED
PARTNERSHIP/LIMITED PARTNERSHIP (Signatures of general partners only)
9. PARTNER'S PRINTED NAME (Last, first, middle) SIGNATURE
X
DATE SIGNED
PARTNER'S PRINTED NAME (Last, first, middle) SIGNATURE
X
DATE SIGNED
PARTNER'S PRINTED NAME (Last, first, middle) SIGNATURE
X
DATE SIGNED
CORPORATION
10. PRINTED NAME (Last, first, middle) SIGNATURE
X
DATE SIGNED
TITLE
President Vice President Chairman of the Board
PRINTED NAME (Last, first, middle) SIGNATURE
X
DATE SIGNED
TITLE
Secretary Asst. Secretary Chief Financial Officer Asst. Treasurer
LIMITED LIABILITY COMPANY
11. The limited liability company is member-run Yes No (If no, complete Item #12 below)
12. NAME OF DESIGNATED MANAGER, MANAGING MEMBER OR DESIGNATED OFFICER (Last, first, middle)
13. MEMBER'S PRINTED NAME (Last, first, middle) SIGNATURE
X
DATE SIGNED
MEMBER'S PRINTED NAME (Last, first, middle) SIGNATURE
X
DATE SIGNED
ABC-211-SIG (rev. 07/19) "SIGN ON"
_
______________
State of California Department of Alcoholic Beverage Control
APPLICATION SIGNATURE SHEET (continued)
APPLICANT'S CERTIFICATION
Under penalty of perjury, each person whose signature appears
below, certifies and says: (1) He/She is an applicant, or one of the
applicants, or an executive officer of the applicant corporation,
named in the foregoing application, duly authorized to make this
application on its behalf; (2) that he/she has read the foregoing and
knows the contents thereof and that each of the above statements
therein made are true; (3) that no person other than the applicant or
applicants has any direct or indirect interest in the applicant or
applicant's business to be conducted under the license(s) for which
this application is made; (4) that the transfer application or proposed
transfer is not made to (a) satisfy the payment of a loan or to fulfill an
agreement entered into more than ninety (90) days preceding the day
on which the transfer application is filed with the Department, (b) to
gain or establish a preference to or for any creditor or transferor, or (c )
to defraud or injure any creditor or transferor; (5) that the transfer
application may be withdrawn by either the applicant or the licensee
with no resulting liability to the Department.
I understand that if I fail to qualify for the license or withdraw this
application, the application fee shall be non-refundable up to the
amount specified in B&P Section 23320.
ADDITIONAL SIGNATURES
14. PRINTED NAME (Last, first, middle) SIGNATURE
X
DATE SIGNED
PRINTED NAME (Last, first, middle) SIGNATURE
X
DATE SIGNED
PRINTED NAME (Last, first, middle) SIGNATURE
X
DATE SIGNED
PRINTED NAME (Last, first, middle) SIGNATURE
X
DATE SIGNED
PRINTED NAME (Last, first, middle) SIGNATURE
X
DATE SIGNED
PRINTED NAME (Last, first, middle) SIGNATURE
X
DATE SIGNED
PRINTED NAME (Last, first, middle) SIGNATURE
X
DATE SIGNED
PRINTED NAME (Last, first, middle) SIGNATURE
X
DATE SIGNED
PRINTED NAME (Last, first, middle) SIGNATURE
X
DATE SIGNED
PRINTED NAME (Last, first, middle) SIGNATURE
X
DATE SIGNED
INSTRUCTIONS AND GENERAL INFORMATION
• Type or print clearly in black or blue ink (do not use red).
• If you need more space for signatures, use Item #14.
Ownership Type (Item #1) - Check the box for the type of
ownership for the business.
File Number (Item #2) - If this is an application for a
transfer or exchange, enter the number assigned to the
specific license being transferred or exchanged.
License Type (Item #3) - Enter the numeric designation for
the license (e.g., Type 21) or description (e.g., Off-Sale
General).
Transaction Type (Item #4) - Check the box for the type of
transaction.
Applicant(s) Name (Item #5) - Enter the name of the
applicant. For a general partnership, the names of the
individual partners.
For a limited partnership, limited
liability company, or a corporation, the name of the entity.
Applicant's Mailing Address (Item #6) - Enter the address
where you wish to receive mail. May be different from the
premises address. Business and mailing addresses are public
information and are available to the public. Please consider
this, especially when listing a mailing address.
Premises Address (Item #7) - Enter the location of the
premises for which the license is applied.
Partnerships (Item #9) - The application must be signed by
each of the partners (e.g., general partnerships, husband and
wife, etc.) Limited Partnerships - The application must be
signed by each of the general partners. Limited partners do
not need to sign.
Corporations (Item #10) - The application must be signed by
two officers of the corporation, one from each of the following
categories:
(a) The chairperson of the board, the president, or
a vice president; and (b) the secretary, assistant secretary, chie
f
financial officer, or assistant treasurer.
Limited Liability Companies (Item #13) - For a limited
liability company that is managed by its members, the
application must be signed by each member or by an officer
authorized by the articles of organization or the operating
agreement to bind the company. For a limited liability
company that is managed by a manager or managers, the
application must be signed by the manager or managers or by
an officer authorized by the articles of organization or the
operating agreement to bind the company.
ABC-211-SIG (rev. 07/19) "SIGN ON"
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Form ABC-211-SIG APPLICATION SIGNATURE SHEET

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Completed 31 January 2020

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