Fillable employee or notarized in accordance with laws (California)

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employee or notarized in accordance with laws (California)

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State of California
Department of Alcoholic Beverage Control
LICENSE TRANSFER REQUEST ("SIGN OFF")
• This form is to be signed by transferors only.
• Read instructions before completing.
• All signatures must be witnessed by an ABC
employee or notarized in accordance with laws
of the State where signed.
1. DISTRICT OFFICE 2. LICENSE NUMBER
3. TRANSACTION TYPE
Exchange
Person to Person Transfer
Premise to Premise Transfer
Other
4. LICENSEE'S NAME (Transferor/Seller) 5. APPLICANT'S NAME (Transferee/Buyer)
6. EXISTING PREMISES ADDRESS
7. LICENSEE'S MAILING ADDRESS (Transferor/Seller) 8. LICENSEE'S PHONE NUMBER
I hereby request surrender of my license under Section 24045.5(b) of the ABC Act so that a Temporary Permit may be issued to the
transferee.
9. SIGNATURE OF TRANSFEROR/SELLER FOR TEMPORARY PERMIT (Only one signature required)
X
DATE SIGNED
10. RENEWAL DUE DATE 11. SURRENDER DATE 12. TEMP. EFFECTIVE DATE 13. TEMP. EXPIRATION DATE
TRANSFEROR'S CERTIFICATION
Under penalty of perjury, each person whose signature appears below, certifies and says: (1) He is the licensee named in the foregoing
transfer application, duly authorized to make this transfer application; (2) that he hereby makes application to surrender all interest in the
license(s) described above and to transfer same to the applicant and/or location indicated on the upper portion of this form, if such transfer is
approved by the Director; (3) that the transfer application or proposed transfer is not made to satisfy the payment of a loan or to fulfill an
agreement entered into more than ninety days preceding the day on which the transfer application is filed with the Department or to gain or
establish a preference to or for any creditor of transferor or to defraud or injure any creditor of transferor; (4) that the transfer application may
be withdrawn by either the applicant or the licensee with no resulting liability to the Department.
SOLE OWNER
14. PRINTED NAME (Last, first, middle) SIGNATURE
X
DATE SIGNED
PARTNERSHIP/LIMITED PARTNERSHIP (Signatures of general partners only)
15. 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
16. 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
17. The limited liability company is member-run Yes No (If no, complete Item #18 below)
18. NAME OF DESIGNATED MANAGER, MANAGING MEMBER OR DESIGNATED OFFICER (Last, first, middle)
ABC INITIALS/DATE (ABC use only)
19. LLC MEMBER'S PRINTED NAME (Last, first, middle) SIGNATURE
X
DATE SIGNED
LLC MEMBER'S PRINTED NAME (Last, first, middle) SIGNATURE
X
DATE SIGNED
ABC-211-A (07/19)
"SIGN OFF"
State of California Department of Alcoholic Beverage Control
LICENSE TRANSFER REQUEST
LICENSE NUMBER
TRANSFEROR'S CERTIFICATION
Under penalty of perjury, each person whose signature appears below, certifies and says: (1) He is the licensee named in the foregoing
transfer application, duly authorized to make this transfer application; (2) that he hereby makes application to surrender all interest in the
license(s) described above and to transfer same to the applicant and/or location indicated on the upper portion of this form, if such transfer is
approved by the Director; (3) that the transfer application or proposed transfer is not made to satisfy the payment of a loan or to fulfill an
agreement entered into more than ninety days preceding the day on which the transfer application is filed with the Department or to gain or
establish a preference to or for any creditor of transferor or to defraud or injure any creditor of transferor; (4) that the transfer application may
be withdrawn by either the applicant or the licensee with no resulting liability to the Department.
ADDITIONAL SIGNATURES
20. 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
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
ABC-211-A (07/19) (reverse)
"SIGN OFF"
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employee or notarized in accordance with laws (California)

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Completed 5 February 2021

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