2. Contact Name*

   First and Last name

3. Phone Number*
4. Email Address*
6. Application Type*
   -- Select One --NewTransferUpgradeTransfer of Location
7. Proposed Location*

   Address, City, State and Zip

9. Name of Entity*
10. Entity Type*
    -- Select One --CorporationLLCPartnershipIndividual
12. Trading As Name/Doing Business As*
14. Applicants*

    Full name of those to appear on the license

16. Class*
    -- Select One --Class A (Packaged Goods)Class B (Restaurant)Class C (Non-profit club)DBR (Brewery)DDS (Distillery)
17. Type*
    -- Select One --Beer OnlyBeer & WineBeer, Wine & LiquorLiquor (Distilleries Only)
18. Endorsements (Additional Privileges)

    Check all that apply

    1. Sunday Permit (Class A)
    2. Beer & Wine Tasting (Class A)
    3. Beer, Wine & Liquor Tasting (Class A)
    4. Delivery (Class A & B)
    5. Patio/Outside Area (Class B & C)
    6. Entertainment (Class B & C)
    7. Growler or Crowler (Class A & B)
    8. Catering (Class B, BWL only)
    9. Cocktails To-go (Class B & C)
    10. Wine Corkage (Class B)
20. Additional Comments
Leave This Blank:


22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

* indicates a required field