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Page 4 PLEASE TYPE OR PRINT ALL INFORMATION <br /> STATE ASSIGNED LICENSE NUMBER 0252 - 44 -005 - 003 <br /> 4.1 IS THE NEAREST ENTRANCE OF THE PLACE TO BE LICENSED WITHIN 200 FEET OF THE NEAREST <br /> ENTRANCE OF ANY CHURCH OR SCHOOL? Yes XX No <br /> IF THE ANSWER IS"YES,"IS A WAIVER SIGNED BY THE APPROPRIATE OFFICIAL ATTACHED TO THIS <br /> APPLICATION? Yes No <br /> 4.2 DOES THE APPLICANT INTEND TO USE ANY VEHICLES FOR THE TRANSPORT OR DELIVERY OF <br /> ALCOHOLIC BEVERAGES? Yes xx No (A TRANSIT INSIGNIA IS NECESSARY BEFORE <br /> ALCOHOLIC BEVERAGES MAY BE TRANSPORTED.) <br /> 4.3 HAS THE APPLICANT FILED AN ANNUAL SPECIAL TAX REGISTRATION AND RETURN FORM (TTB F <br /> 5630.5)WITH THE FEDERAL ALCOHOL AND TOBACCO TAX AND TRADE BUREAU? <br /> XX Yes No ,!c c;l; -. ,t• it .._r:.i:,; <br /> IF"YES,"DATE FILED 6 / 30 / 2006 No Change in existing registration info <br /> 4.4 WILL ANY BUSINESS OTHER THAN THE SALE OF ALCOHOLIC BEVERAGES BE CONDUCTED ON THE <br /> PREMISES TO BE LICENSED? XX Yes No <br /> IF THE ANSWER IS"YES,"INDICATE THE NATURE OF THE BUSINESS AND WHO WILL CONDUCT IT BY <br /> RESPONDING TO THE FOLLOWING QUESTIONS: <br /> Restaurant Applicant Other <br /> Catering Applicant Other <br /> Hotel/Motel Applicant Other <br /> Amusements Applicant Other <br /> �-N.J. Lottery Applicant Other <br /> Grocery or Delicatessen Applicant Other <br /> XX Other(specify) XX Applicant Other <br /> Items allowed under 12.3A <br /> 4.5 IF SOMEONE OTHER THAN THE APPLICANT WILL OPERATE THE OTHER BUSINESS ON THE LICENSED <br /> PREMISES, ANSWER THIS QUESTION. IF THERE IS MORE THAN ONE INDIVIDUAL OR COMPANY, <br /> ATTACH A SEPARATE PAGE LISTING THE REQUESTED INFORMATION FOR EACH OPERATOR. <br /> Business to be operated <br /> Name of company/individual N/A <br /> (Last Name, First Name or Corporate Name) <br /> Street Address <br /> Number Street Name <br /> Municipality State <br /> Zip - NJ Sales Tax Certificate of Authority No. <br />