Original Alcohol Beverage License Application (AT-106)

Type of License Requested

Class "A" beer

Class "B" beer

"Class C" wine

"Class A" liquor

"Class A" liquor (cider only)

"Class B" liquor

Reserve "Class B" liquor

"Class B" (wine only) winery

Legal Business Name (registered entity name or individual's name if sole proprietorship)

Trade Name or DBA

Premises Address

Premises City & Zip Code

County

Municipality

Aldermanic District

Mailing Address (if different from premises address)

Premises/Business Phone Number

Premises Email

Wisconsin Seller's Permit Number

FEIN Number

Upload a copy of your WI Seller's Permit

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Choose which type of legal entity your business is:

Sole Proprietor

Limited Liability Company

Partnership

Corporation

Nonprofit Organization

Premises description: Describe building or buildings where alcohol beverages are to be sold and stored. Describe all rooms, including living quarters, if used, for the sales, service, consumption, and/or storage of alcohol beverages and records. Alcohol beverages may be sold and stored ONLY on the premises described in this application.

Have the partners, agent, or sole proprietor satisfied the responsible beverage server training requirement for this license period? Submit a copy of Responsible Beverage Server Course Certificate.

Yes

Submit a copy of Responsible Beverage Server Training Course Certificate.

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Does the applicant business or its partners, officers, directors, managing members, or agent hold a direct or indirect interest in any alcohol beverage wholesaler or producer (e.g., brewer, brewpub, winery, distillery)?

Yes

If yes, please explain using the space below.

Are you a Corporation or LLC?

Yes

State of Registration

Date of Registration

Is the applicant business owned by another corporation or LLC?

Yes

Please provide the name and FEIN of the parent company, include parent company members in next section, and attach Form AT-103 for all of the parent company's principal members, managers, officers, or directors.

Does the parent company or any of its officers, directors, managing members, or agent hold any direct or indirect interest in any other alcohol beverage wholesaler or producer (e.g., brewer, brewpub, winery, distillery):

Yes

Agent's Name (Last, First)

Agent's Phone

A Supplemental Questionnaire, Form AT-103, must be completed and attached to this application for each person involved in the applicant business and any parent company as indicated above.Persons in the applicant business include: sole proprietor, all officers, directors, and agent of a corporation or nonprofit organization, all partners of a partnership, and all managing members and agent of a limited liability company.

Last Name, First Name

Title

Phone

Last Name, First Name

Title

Phone

Last Name, First Name

Title

Phone

Last Name, First Name

TItle

Phone

Last Name, First Name

Title

Phone

Last Name, First Name

Title

Phone

Who must sign this application?

Sole proprietor
one general partner of a partnership
one corporate officer
one managing member of an LLC

READ CAREFULLY BEFORE SIGNING: Under penalty provided by law, I have answered each of the above questions 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 responsiblities 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 allow inspection. Such refusal is a misdemeanor and grounds for revocation of this license. I undertand 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.

Name (Last, First, M.I.)

Title

Phone

Today's Date