Alcohol Beverage License Application Renewal (AT-115)

For the license period beginning and ending:

July 1, yyyy *

June 30, yyyy *

License(s) Desired (Up to two)

Class "A" Beer

Class "A" Liquor

Class "A" Liquor (cider)

"Class C" Wine

"Class B" Beer

"Class B" Liquor

Reserve "Class B" Liquor

"Class B" (winery)

Premises/Business Information

Legal Business Name (Registered Entity Name or Individual's Name if Sole Proprietorship)

Trade Name or DBA

County

Municipality

Aldermanic District

Mailing Address (if Different from Premises Address)

FEIN (Sole Proprietors use Social Security Number)

Wisconsin Seller's Permit Number

Premises Phone

Premises Email

Entity Type (check one)

Sole Proprietor

Partnership

Limited Liability Company

Corporation

Nonprofit Corporation

Questions

Do you want to adjust your premises to include more or less territory?

Yes

If yes, please describe your new premises below.

For Corporation/LLC Applicants Only:

Has your designated agent changed since your most recent application was submitted?

Yes

If yes, submit an approved Responsible Beverage Server course certificate here.

Click Here to Upload

Have any of your partners, members, officers, directors, managers, or agent changed since your most recent application was submitted?

Yes

Please list the names, titles and phone numbers of any changed members or agents AND attach FORM AT-103 for all NEW members.

Last Name

First Name

Phone Number

Title

Choose to add or remove this person.

Add

Remove

Last Name (if none, enter n/a)

First Name (if none, enter n/a)

Phone Number (if none, enter n/a)

Title (if none, enter n/a)

Choose to add or remove this person.

Add

Remove

Last Name (if none enter n/a)

First Name (if none, enter n/a)

Phone Number (if none, enter n/a)

Title (if none, enter n/a)

Choose to add or remove this person.

Add

Remove

Has the licensee, or any officer, director, stockholder, member, manager, or agent had any changes to their most recently filed Form AT-103 including updated contact information, changes in address, criminal history, interest restrictions, etc? IF YES, AFFECTED MEMBERS SHOULD SUBMIT UPDATED AT-103s

Yes

Does the entity or any of its officers, directors, or agents hold any direct or interest in any other alcohol beverage wholesaler or producer (e.g. brewery, brewpub, winery, distillery) in Wisconsin?

Yes

If yes, please explain.

Is the person or business identified in the Premises/Business Information, the genuine seller of alcohol beverages and operator of the business (e.g. reporter of profit/loss from the sale of alcohol beverages on their income tax return, holder of the seller's permit for the business location, payer of employees, taxes, utilities, and other expenses for the business, etc)?

Yes

Is the business indebted to any wholesaler beyond 15 days for beer or 30 days for liquor?

Yes

Are all municipal property taxes, assessments, or other fees incurred by this business reported and paid?

Yes

Attestation

Who must sign this application?

• Sole proprietor • One general partner of a partnership • One corporate officer • One member/manager of an LLC

READ CAREFULLY BEFORE SIGNING: Under penalty of law, I have answered each of the above questions completely and truthfully. I agree that I am acting solely on behalf of the applicant business and not on behalf of any other individual or entity seeking the license. Further, I agree that the rights and responsibilities conferred by the license(s), if granted, will not be assigned to another individual or entity. I agree to operate this business according to the law, including but not limited to, purchasing alcohol beverages from state authorized wholesalers. I understand that lack of access to any portion of a licensed premises during inspection will be deemed a refusal to permit inspection. Such refusal is a misdemeanor and grounds for revocation of this license. I understand that any license issued contrary to Wis. Stat. Chapter 125 shall be void under penalty of state law. I further understand that I may be prosecuted for submitting false statements and affidavits in connection with this application, and that any person who knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted.

Signature

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Date

Title/Member

Phone Number

Preparers' email (n/a if not needed)