Fillable Form Dr 8404 - Colorado Liquor Retail License Application (Page 4 of 4) in pdf

Name

Type of License

Account Number

23. Tax Distraint Information. Does the applicant or any other person listed on this application including its partners, officers, directors,

Yes No

stockholders, members (LLC) or managing members (LLC) and any other persons with a 10% or greater financial interest in the applicant

currently have an outstanding tax distraint issued to them by the Colorado Department of Revenue?

If yes, provide an explanation and include copies of any payment agreements.

24. 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 ownership of 10% or more in the

applicant. All persons listed below must also attach form DR 8404-I (Individual History Record), and submit fingerprint cards to the local

licensing authority.

Name

Home Address, City & State

DOB

Position

%Owned

Name

Home Address, City & State

DOB

Position

%Owned

Name

Home Address, City & State

DOB

Position

%Owned

Name

Home Address, City & State

DOB

Position

%Owned

Name

Home Address, City & State

DOB

Position

%Owned

** If applicant is owned 100% by a parent company, please list the designated principal officer on above.

** Corporations - the President, Vice-President, Secretary and Treasurer must be accounted for above (Include ownership percentage if applicable)

** 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 and does not have financial interest in a

prohibited liquor license pursuant to Title 47 or 48, C.R.S.

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.

Authorized Signature

Printed Name and Title

Date

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)

The Local Licensing Authority Hereby Affirms that each person required to file DR 8404-I (Individual History Record) or a DR 8000 (Manager Permit) has been:

Fingerprinted

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 _____________________

Will conduct inspection upon approval of state licensing authority

Yes No

Is the Liquor Licensed Drugstore (LLDS) or Retail Liquor Store (RLS) within 1,500 feet of another retail liquor license for off-premises

sales in a jurisdiction with a population of > 10,0000?

Is the Liquor Licensed Drugstore(LLDS) or Retail Liquor Store (RLS) within 3,000 feet of another retail liquor license for off-premises

sales in a jurisdiction with a population of < 10,0000?

NOTE: The distance shall be determined by a radius measurement that begins at the principal doorway of the LLDS/RLS premises for

which the application is being made and ends at the principal doorway of the Licensed LLDS/RLS.

Does the Liquor-Licensed Drugstore (LLDS) have at least twenty percent (20%) of the applicant's gross annual income derived from

the sale of food, during the prior twelve (12) month period?

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., and Liquor Rules. Therefore, this application is approved.

Local Licensing Authority for

Telephone Number

Town, City

County

Signature

Title

Date

Signature

Title

Date