APPLICATION FOR RETAIL ALCOHOL PERMIT

City of Denham Springs Permit to be issued for the

Attn: Business License Office Calendar Year Ending

P O Box 1629 December 31,

Denham Springs, LA 70726

Permit to be

Issued to:

(Owner-Name of Individual, Name of Partners or Corporation)

1. Application is for an Alcohol Permit as a

□ Class “A-R” Retail Alcohol Restaurant Outlet (1/2% or more alcoholic beverages by volume) (High-$500 or Low-$75)

City Ordiance Sec. 10-94. Requirements for issuance of “A-R” Permits.

A restaurant establishment shall be defined as an establishment:

a. Which operates a place of business whose purpose and primary function is to take orders for and serve food items;

b. Which serves alcoholic beverages in conjunction with meals;

c. Which serves food on all days of operation;

d. Which grosses sixty percent of its average monthly revenue from the sale of food, food items, and non-alcoholic beverages;

$ Sales from Alcoholic Beverages

□ Class “B” Retail Package Outlet (1/2% or more alcoholic beverages by volume) (High-$500 or Low-$60)

2. Kind of ownership, i.e. Individual, Partnership, or a Corporation?

3. Does Applicant hold Local Alcohol Permit for current year at any other location? What Kind?

4. Has the Applicant ever been denied a State or Local Alcohol Permit?

5. Has Applicant applied for, or holds any other Alcohol Permit? What Kind?

6. a. Is Applicant the owner of the premises to be occupied? Yes No

b. If no, does Applicant hold a bona fide written lease? Yes No

d. Describe part of building to be occupied by business:

7. Date started, or to start at this address:

10. Does Applicant owe any excise tax (sales, occupational license,

income, franchise, etc) to the state or any parish or municipality?

11. Is this application by a new owner to take over a going business that

has been selling liquor regularly and continuously to the present time?

b. Sex: Race: Social Security #:

c. Residence Address:

d. Date of Birth: Place of Birth:

e. Are you a citizen of the United States? The State of Louisiana? Over 18 years of Age?

f. How did you become a citizen?

g. Have you resided in the State of Louisiana continuously for a period of not less than two (2) years next preceding the date of filing

this application?

h. Have you ever been convicted of a felony under the laws of the United States, the State of Louisiana or any other state?

If yes, a proof of pardon and restoration of citizenship must be submitted with this application.

i. Have you ever been convicted in this state or in any other state or by the United States of soliciting for prostitution, pandering,

l. Have you ever been convicted for violating any of the provisions of the Beer or Liquor Laws of this State?

m. Are you married? If yes, is spouse eligible for permit?

n. Do you or your spouse hold interest in any establishment holding an Alcohol Permit other than the type applied for herein?

If yes, list the following:

Permit # Trade Name Address Kind of Interest % Equity

o. Have you ever used any other name other than the one given herein? If yes, give details below:

Name Used Place Used Date

Failure to file application before beginning business, or, for renewal permit later than December 10

of each year will incur penalties, to include 25% of permit fee.

a. Name: Drivers License #:

b. Sex: Race: Social Security #:

c. Residence Address:

d. Date of Birth: Place of Birth:

e. Are you a citizen of the United States? The State of Louisiana? Over 18 years of Age?

f. How did you become a citizen?

g. Have you resided in the State of Louisiana continuously for a period of not less than two (2) years next preceding the date of filing

this application?

h. Have you ever been convicted of a felony under the laws of the United States, the State of Louisiana or any other state?

If yes, a proof of pardon and restoration of citizenship must be submitted with this application.

i. Have you ever been convicted in this state or in any other state or by the United States of soliciting for prostitution, pandering,

l. Have you ever been convicted for violating any of the provisions of the Beer or Liquor Laws of this State?

m. Are you married? If yes, is spouse eligible for permit?

n. Do you or your spouse hold interest in any establishment holding an Alcohol Permit other than the type applied for herein?

If yes, list the following:

Permit # Trade Name Address Kind of Interest % Equity

o. Have you ever used any other name other than the one given herein? If yes, give details below:

Name Used Place Used Date

AFFIDAVIT