CC_Minutes_2013_1118 - Laserfiche WebLink

Home

Page 5 PLEASE TYPE OR PRINT ALL INFORMATION STATE ASSIGNED LICENSE NUMBER 0252 44 005 003 ALL APPLICANTS ANSWER THE FOLLOWING 5.1 IS THE APPLICANT OR ANY OTHER PERSON MENTIONED IN THIS APPLICATION A POLICE OFFICER OR HOLD ANY POSITION ENTRUSTED WITH THE ENFORCEMENT OF ANY LAWS CONCERNING ALCOHOLIC BEVERAGES IN ANY MANNER WHATSOEVER? Yes XX No If the answer is"Yes,"complete the following: Name of individual _ Last Name First Name Middle Initial Title of position held Name of Employing Agency 5.2 DOES THE APPLICANT OR ANY OTHER PERSON MENTIONED IN THIS APPLICATION, OR ANY PERSON HAVING A BENEFICIAL INTEREST IN THE LICENSED BUSINESS, HOLD OFFICE IN THE UNIT OF GOVERNMENT ISSUING THE LICENSE? Yes XX No IF THE ANSWER IS"YES,'COMPLETE THE FOLLOWING: Name of Individual Last Name First Name Middle Initial Title of Office Municipality 5.3 DOES THE APPLICANT OR ANY OTHER PERSON MENTIONED IN THIS LICENSE APPLICATION, OR ANYONE WITH A BENEFICIAL INTEREST IN THE LICENSED BUSINESS, DIRECTLY OR INDIRECTLY, HAVE ANY INTEREST IN ANY BREWERY, WINERY, DISTILLERY, RECTIFYING AND BLENDING PLANT, IMPORTER OR WHOLESALE ALCOHOLIC BEVERAGE BUSINESS, AS OWNER, PART OWNER, LANDLORD, TENANT, MORTGAGE HOLDER OR AS A STOCKHOLDER, OFFICER, DIRECTOR,AGENT, EMPLOYEE OR OTHERWISE? Yes XX No IF THE ANSWER IS"YES,"ATTACH AN AFFIDAVIT EXPLAINING THE RELATIONSHIP AND NATURE OF THE INTEREST AND COMPLETE THE FOLLOWING: A. New Jersey license number, if applicable B. IF THE BUSINESS DOES NOT HOLD A NEW JERSEY LIQUOR LICENSE,ANSWER THE FOLLOWING QUESTIONS: Name of entity conducting business (Corporation, Partnership or Individual) (Last Name, First Name, Middle Initial or Corporate Name) Street Address Number Street Name P.O. Box# Municipality State Zip - Type of Business