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1. READ CAREFULLY. ANSWER COMPLE I ACCURATELY§53-125(5) <br /> Has anyone who is a party to this application,or their spouse EVER :- convicted of or plead guilty to any charge. Charge <br /> means any charge alleging a felony,misdemeanor,violation o f-• or state law;a violation of a local law,ordinance or <br /> resolution. List the nature of the charge,where the charge ' < and the year and month of the conviction or plea. Also <br /> list any charges pending at the time of this application. if more than one party,please list charges by each individual's name. <br /> acludel ffic violations. Commission must be notified of any arrests and/or convictions that may occur after the date of <br /> signing this application. <br /> YES Jt NO <br /> If yes,please explain below or attach a separate page <br /> Name of Applicant Date of Where Description of Charge Disposition <br /> Conviction Convicted <br /> (mm/yyyy) (city&state) <br /> NA‘c1Na.21 1500'9 Eadd Hatt sfaa4 I n eAr th,CKat <br /> Ib <br /> ,CN\a?, 9015 k aoot ru.it44 Z Ely, it <br /> Itt.le .280;"AV /- if t;r4 f !i*ISoat,de 4garese 7;c/<et <br /> 2. Are you buying the business of a current retail liquor license? <br /> YES I` NO <br /> If yes,give name of business and liquor license number <br /> a)Submit a copy of the sales agreement <br /> b)Include a list of alcohol being purchased,list the name brand,container size and bow many <br /> c)Submit a list of the furniture,fixtures and equipment <br /> 3. Was this premise licensed as liquor licensed business within the last two(2)years? <br /> If YES NO <br /> If yes,give name and license number G a 7g 5 <br /> 4. Are you filing a temporary operating permit(TOP)to operate during the application process? <br /> YES 9 NO <br /> If yes: <br /> a) Attach temporary operating permit(TOP)(form 125) <br /> b) TOP will only be accepted at a location that currently holds a valid liquor license. <br /> FORM tOO <br /> REV MAY 2015 <br /> PAGE 5 <br />