License Application For Operator'S (Bartender'S) License - Town Of Nekimi
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2LICENSE APPLICATION for OPERATOR’S (BARTENDER’S) LICENSE
TOWN OF NEKIMI
DATE RECEIVED___ _________
Operator License
NEW
RENEWAL
Fee: $60.00 (Two Year License)
I, the undersigned, do hereby make application to the local governing body of the Town of Nekimi, Winnebago County, Wisconsin for
a license to serve, from the date a license is granted thru _____ ____, inclusive (unless sooner revoked), Fermented Malt Beverages and
Intoxicating Liquors, subject to the limitations imposed by Section 125.32(2) and 125.68(2) of the Wisconsin statutes and acts
amendatory thereof and supplementary thereto, and hereby agree to comply with all laws, resolutions, ordinances and regulations,
Federal, State or Local, affecting the sale of such beverages and liquors if a license be granted to me.
FEES ARE NON-REFUNDABLE
Answer all questions completely. PLEASE PRINT.
SECTION 1 – APPLICANT INFORMATION
Applicant Name (Last, First, MI)
Maiden Name
Street Address
City
State
Zip
Driver’s License Number
State License Issued In:
Date of Birth
Sex
Home Phone Number
Cell Phone Number
Name and Address of Establishment where you will be selling alcohol
SECTION 2 –RECORDS
Have you EVER had an Operator’s (Bartender’s) License?
YES
NO
If YES, where? _____________________________________________________________________________
As required by Wisconsin Statutes section 125.17(6), have you completed the alcohol awareness course? YES
NO
If so, where?_______________________________________________________________________________
Have you EVER been convicted of a felony, misdemeanor, or ANY law of WI or of the U.S.A.? YES
NO
If YES, provide date, location, and explanation of violation (Please be specific)
Date of Conviction:______________Name of Court:
________________________________________________
Nature of Violation:
__________________________________________________________________________
SECTION 3 – NOTICE
I, ________________________________________, swear that the information provided in this application is true and
correct to the best of my knowledge and belief and that I am the person who signed the foregoing application for an
operator’s license.
X____________________________________
Applicant sign here.
State of Wisconsin
Winnebago County
Subscribed and sworn before me this ____________ day of _______________________, _____________
_____________________________________________
Notary Public _________________County, Wisconsin
My Commission Expires ________________________
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