Liquor Licence Application Form - Colorado

19. If applicant is a corporation, partnership, association or limited liability company, applicant must list ALL OFFICERS, DIRECTORS,

GENERAL PARTNERS, AND MANAGING MEMBERS. In addition applicant must list any stockholders, partners, or members with OWNER-

SHIP OF 10% OR MORE IN THE APPLICANT. ALL PERSONS LISTED BELOW must also attach form DR 8404-I (Individual History record),

and submit finger print cards to their local licensing authority.

DR 8404 (05/07/09) Page 4

Registered Agent (if applicable) Address for Service

REPORT AND APPROVAL OF LOCAL LICENSING AUTHORITY (CITY/COUNTY)

Date application filed with local authority Date of local authority hearing

(for new license applicants; cannot be less

than 30 days from date of application 12-47-311 (1)) C.R.S.

TOWN, CITY

COUNTY

Authorized Signature Title Date

Date

The foregoing application has been examined; and the premises, business to be conducted, and character of the applicant are satisfactory.

We do report that such license, if granted, will meet the reasonable requirements of the neighborhood and the desires of the adult inhabitants,

and will comply with the provisions of Title 12, Article 46 or 47, C.R.S. THEREFORE, THIS APPLICATION IS APPROVED.

DOB

% OWNED*

NAME POSITION

HOME ADDRESS, CITY & STATE

TitleSignature

Signature (attest)

Title

Local Licensing Authority for

Telephone Number

OATH OF APPLICANT

I declare under penalty of perjury in the second degree that this application and all attachments are true, correct, and complete

to the best of my knowledge. I also acknowledge that it is my responsibility and the responsibility of my agents and employees

to comply with the provisions of the Colorado Liquor or Beer Code which affect my license.

PARTNERSHIP Partnership Agreement (General or Limited) Husband and Wife partnership (no written agreement)

LIMITED LIABILITY COMPANY Articles of Organization Cert. of Authority (if foreign company) Operating Agrmt.

ASSOCIATION OR OTHER Attach copy of agreements creating association or relationship between the parties

CORPORATION Cert. of Incorp. Cert. of Good Standing (if more than 2 yrs. old) Cert. of Auth. (if a foreign corp.)

Additional Documents to be submitted by type of entity

*If total ownership percentage disclosed here does not total 100% applicant must check this box

Applicant affirms that no individual other than these disclosed herein, owns 10% or more of the applicant

THE LOCAL LICENSING AUTHORITY HEREBY AFFIRMS:

That each person required to file DR 8404-I (Individual History Record) has:

Been fingerprinted .........................................................................................................................................................................................

Been subject to background investigation, including NCIC/CCIC check for outstanding warrants ...............................................................

That the local authority has conducted, or intends to conduct, an inspection of the proposed premises to ensure that the applicant is in

compliance with, and aware of, liquor code provisions affecting their class of license .......................................................................................

(Check One)

Date of Inspection or Anticipated Date _____________________________________

Upon approval of state licensing authority.

Yes

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