(Name of Corporation / Organization / Limited Liability Company)
(Signature of Ofcer / Member / Manager)
to act for the corporation/organization/limited liability company with full authority and control of the premises and of all business relative
to alcohol beverages conducted therein. Is applicant agent presently acting in that capacity or requesting approval for any corporation/
organization/limited liability company having or applying for a beer and/or liquor license for any other location in Wisconsin?
(Signature of Agent)
(Home Address of Agent)
Submit to municipal clerk.
All corporations/organizations or limited liability companies applying for a license to sell fermented malt beverages and/or intoxicating liquor
must appoint an agent. The following questions must be answered by the agent. The appointment must be signed by an ofcer of the
corporation/organization or one member/manager of a limited liability company and the recommendation made by the proper local ofcial.
How long immediately prior to making this application has the applicant agent resided continuously in Wisconsin?
Place of residence last year
For:
By:
ACCEPTANCE BY AGENT
, hereby accept this appointment as agent for the
(Print / Type Agent’s Name)
corporation/organization/limited liability company and assume full responsibility for the conduct of all business relative to alcohol
beverages conducted on the premises for the corporation/organization/limited liability company.
APPROVAL OF AGENT BY MUNICIPAL AUTHORITY
(Clerk cannot sign on behalf of Municipal Ofcial)
Agent’s age
Date of birth
(Date)
I hereby certify that I have checked municipal and state criminal records. To the best of my knowledge, with the available information,
the character, record and reputation are satisfactory and I have no objection to the agent appointed.
Approved on
(Date)
by
(Signature of Proper Local Ofcial)
Title
(Town Chair, Village President, Police Chief)
AT-104 (R. 4-18)
I,
Wisconsin Department of Revenue
Schedule for Appointment of Agent by Corporation / Nonprot
Organization or Limited Liability Company
a corporation/organization or limited liability company making application for an alcohol beverage license for a premises known as
The undersigned duly authorized ofcer/member/manager of
(Registered Name of Corporation / Organization or Limited Liability Company)
Is applicant agent subject to completion of the responsible beverage server training course? Yes No
To the governing body of: County of
If so, indicate the corporate name(s)/limited liability company(ies) and municipality(ies).Yes No
(Trade Name)
located at
appoints
(Name of Appointed Agent)
(Home Address of Appointed Agent)
Town
Village of
City
Any person who knowingly provides materially false information in an application for a license may be required to forfeit not more than
$1,000.
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