TOWN OF CEDAR BLUFF, ALABAMA

APPLICATION FOR

________________________________

(Type of License Applied For)

Date Denied ____________________ Date Approved _______________________

Name of Applicant(s): _____________________________________________________

Name and address of individual applicant and all partners, officers and directors.

Name Address DOB SSN

______________________________________________________________________________________

Are all persons listed above citizens of the United States? ____________________

If naturalized, give place and date: _______________________________________

___________________________________________________________________

If applicant is corporation, is fifty-one percent (51%) or more, of capital stock owned

By citizens of the United States? _________________________________________

NOTE: If a corporation, give place and date of incorporation or issuance of certificate of

authority to do business in Alabama:

Book _______________ Page ________________ County _______________________

Date _______________

Trade Name: _________________________________________________________

Phone Number: _______________________________________________________

Location: ____________________________________________________________

Length of time in business at this location: __________________________________

Mailing Address: ______________________________________________________

Name, trade name and license number of previous licensee: ____________________

____________________________________________________________________

Year _______________ Type _______________ Number _____________

Owner of real estate for which license is desired: _____________________________

Is establishment equipped with tables and chairs? ____________________________

Is the manager a citizen of the United State? _________ If no, explain ___________

____________________________________________________________________

Has this manager or applicant, whether individual member or partnership of the

association of officers and directors or corporation itself, ever been refused a

federal state permit or license or had permit or license suspended, revoked or

declined? ___________ If yes, explain ___________________________________

___________________________________________________________________

What gambling paraphernalia or slot machine equipment is on the premises? _____

___________________________________________________________________

Do you allow dancing? ________________________________________________

Contemplate allowing dancing? _________________________________________

Is live entertainment provided? __________________________________________

Are the applicant(s) named above, the only person(s) having any manner of pecuniary

interest in the business sought to be licensed? __________ (If not, explain) _________

______________________________________________________________________

These premises are located in the corporate limits of the Town of Cedar Bluff, Alabama.

are any of the applicants, whether individual, member of partnership or association, or

officers and directors of corporation or the corporation itself, in any way interested in a

pecuniary manner, either directly or indirectly, in the profits of any other class of

business regulated under by alcoholic beverage control statutes, regulations, and/or

ordinances? ____________________________________________________________

Does any applicant own or control, directly or indirectly, or hold lien against any real

Or personal property which is rented, leased or used in the conduct of business by the

Holder of any alcoholic beverage license issued by the State or the Town?__________

Is any applicant receiving, either directly or indirectly, any loan, credit, monies or the

equivalent thereof from any other licensee, or from or through a subsidiary or affiliate

of another licensee, or from any firm, association or corporation operating under or

regulated by alcoholic beverage control statutes, regulations, and/or ordinances? ____

Facilities

Is this premises’ kitchen equipped? __________________________________________

Is kitchen apart from, but adjacent to, the dining room? __________________________

Is place of business habitually and principally used for providing food to the public? ___

If kitchen is not equipped, is any type food served? ______________________________

If yes, explain: ___________________________________________________________

Are these premises equipped with services and facilities that provide for on-premises

consumption of liquor? ____________________________________________________

Will this business be operated primarily as a package store? _______________________

Number of seats at Tables ______ Booths ___________ Stools ________ Total _______

If a common carrier, does each vehicle seat ten or more persons? ___________________

For a SPECIAL RETAIL LICENSE, more than thirty (30) days:

Starting ______________________ Ending _____________________________

For a SPECIAL RETAIL LICENSE, less than thirty (30) days:

Starting ______________________ Ending _____________________________

For a SPECIAL RETAIL LICENSE, (not to exceed 7 days):

Starting ______________________ Ending _____________________________

(Must be filed 25 days in advance of event for which license is applied for)

If applying for a Cub license:

Does the Club charge and collect dues from elected members? _____________________

How many paid up members are there in the Club? ______________________________

Are regular meetings held? ____________________ Patriotic? _______________

Is business conducted through officers regularly elected? _________________________

Are members admitted by written application, investigation and ballot? ______________

For what purpose is the Club organized and operated?

Social ____________________ Patriotic ____________________________

Political __________________ Athletic ____________________________

Is the property used, and do the advantages of the club, belong to all the members? ____

_______________________________________________________________________

Does the Club maintain in the establishment, a special space and accommodation where,

in consideration of payment, food, with or without lodging, is habitually served? ______

_______________________________________________________________________

Do the operations of the Club inure to the benefit of any individual members, officers,

Directors, agents or employees of the Club, rather to the benefit of the entire

membership? ____________________________________________________________

List below charges for law violations, in the last ten years, if any, of each person interested in this application, including manager, whether as a sole applicant, partner, officer, or member:

(DO NOT include traffic violations, except D.U.I. and reckless driving) If no record, state NONE.

Name Violation Name of Date Disposition

Charge Court of Case

_____________________________________________________________________________

SKETCH OF NEIGHBORHOOD/ENTIRE PREMISES

W E

Make proper designation of approximate location of a church, school, day care facility, or private residence to the premises.

The undersigned agree, if a license is issued as hereinabove applied for, to comply at all times with and to fully observe all laws and regulations of the State of Alabama relative to the handling of alcoholic beverages. The undersigned, if issued a license as herein requested, further agrees to obey all rules and regulations promulgated by the Board relative to all alcoholic beverages received in this State. The undersigned, if issued a license as herein requested, also agrees to allow and hereby invites duly authorized agents of the Alabama Alcoholic Beverage Control Board and any duly commissioned law enforcement officer of the State, County or Municipality in which the licensed premises are located, to enter and search without a warrant, the licensed premises or any building owned or occupied by him in connection with, adjoining, or adjacent therein, whether connected or not, and whether used by him as his private dwelling or not, at any time. The undersigned understands that should he or she violate any provisions of State law or any of the rules and regulations promulgated by the Board, the license shall be subject to revocation. The undersigned further understands and agrees that no changes in the manner of operation and no deletion or discontinuance of any services or facilities as described in this application will be allowed without prior written approval of the Town of Cedar Bluff and the Alabama Alcoholic Beverage Control Board.

Signed ___________________________________

Applicant

___________________________________

Printed Name

By: ___________________________________

Its: ___________________________________

STATE OF ALABAMA )

)

COUNTY OF CHEROKEE )

The undersigned Applicant for the Alcoholic Beverage license, requested by the foregoing applicant, hereby swears or affirms that he or she has read said application and all the statements therein and that the facts set forth therein, are true and correct, and that the applicant is the only person interested in the business for which license is requested.

Sworn to and subscribed before me on this _________ day of _________________, 2006.

_______________________________ __________________________________

Name of Notary Public Signature of Affiant

The space below is provided for use by the Town Council for approval or disapproval of the above application.

This application was submitted to the Town Council of the Town of Cedar Bluff, Alabama, on ____________________, 2006, said application was _________________________________

(Approved/Disapproved)

I certify that the above is an official action of the Town of Cedar Bluff, Alabama.

WAIVER AND AUTHORIZATION TO PERFORM BACKGROUND CHECK

RE: TOWN OF CEDAR BLUFF, ALABAMA

APPLICATION FOR ALCOHOLIC BEVERAGE LICENSE

DATE: _______________________________________________________________________

I respectfully request and authorize the Town of Cedar Bluff, Alabama, Town Clerk and Police Chief to furnish any and all information that you have on record concerning my background check relating to the above-referenced “Application for Alcoholic Beverage License.”

This information will be a part of the individual application for Alcoholic Beverage license file and may be reviewed by Cedar Bluff officials and employees in considering my application for an alcoholic beverage license.

In consideration of the review of application for license by the Town of Cedar Bluff officials and employees, I hereby hold harmless and give full release and authorization from any and all liability or damage which may result from furnishing such information.

________________________________ ___________________________________

Applicant’s Signature Applicant’s Printed Name

___________________________________

Applicant’s Social Security Number

___________________________________

Applicant’s Date of Birth

STATE OF ALABAMA )

COUNTY OF CHEROKEE )

Before me a Notary Public in and for said County and State personally appeared the above signed Applicant, who after being duly sworn, acknowledged that he/she read this document and had its purpose and intent fully explained to him/her and with such knowledge said Applicant freely executed this instrument by his/her own hand.

Subscribed before me in my presence this ____ day of _____________________, 2006.

___________________________________ My commission expires ________________

Notary Public