Oglethorpe County, Georgia
APPLICATION FOR LICENSE TO SELL ALCOHOLIC BEVERAGES FOR 20
Instructions: Every question must be fully and correctly USE ONLY
answered, typed or legibly hand-printed. If the space Date Received _____________
provided is not sufficient, answer the question on a separate Investigation Fee Paid ( )
sheet and indicate in the space provided that such separate Fingerprints Submitted ( )
sheet is attached. When completed the application must be Clearance From:
dated, signed and verified under oath by the applicant and Sheriff's Dept ( )
filed with the Board of Commissioners of Oglethorpe County, Planning & Zoning ( )
341 West Main Street Lexington, GA 30648, together with Proof of Advertising ( )
all required supporting documents. Public Hearing _____________
( ) Approved for License ( ) Disapproved
TYPE OF LICENSE: ( ) NEW ( ) RENEWAL Fee Paid $_______________
License # _______ Date Issued _________
WHOLESALE LIQUOR SALES $5,000 ( )
RETAIL LIQUOR-PACKAGE SALES $2,000 ( )
FULL NAME OF PERSON MAKING APPLICATION (Please spell out name, no initials) SOCIAL SECURITY NUMBER
CORPORATE NAME, IF CORPORATION (NAME MUST BE AS REGISTERED WITH SECRETARY OF STATE
ADDRESS OF LEGAL RESIDENCE (STREET, ROAD, RFD NO. AND ROUTE, P.O. BOX NO.) RESIDENCE TELEPHONE NUMBER
CITY STATE ZIP CODE COUNTY OF RESIDENCE
TRADE NAME OF BUSINESS APPLYING FOR LICENSE GA SALES TAX NUMBER
BUSINESS LOCATION ADDRESS
CITY STATE ZIP CODE BUSINESS TELEPHONE NUMBER
MAILING ADDRESS, IF DIFFERENT (MAIL NOT RECEIVED AT PLACE OF BUSINESS) CITY STATE ZIP CODE
Has this place of business or anyone connected therewith, been cited or charged at any time with any Violation of Georgia Law,
Federal Law or any rule or regulation of the State Revenue Commissioner or any rule or regulation of the County?
Yes ( ) No ( ) If Yes, give full details.
List the full name, Social Security Number, and other pertinent information for each person, firm, or corporation
having any interest in this application and the % (percentage) of interest. (Attach Exhibits if Necessary)
FULL NAME SOC. SEC. # RESIDENCE ADDRESS % INTEREST
List all other businesses engaged in the sale of alcoholic beverage of any type that any of their persons, firms,
or corporations listed in the above question are interested in, employed by, or associated with in any way whatsoever.
(Attach Exhibits if Necessary)
FULL NAME NAME OF BUSINESS BUSINESS ADDRESS % INTEREST
List the full name and address of the owner of the building, the owner of the land, and all leasers and sublease's.
(Attach Exhibits if Necessary)
FULL NAME SOC. SEC. # RESIDENCE ADDRESS RELATIONSHIP
How much of the capital of this business is borrowed and from whom? (Attach Exhibits if Necessary)
AMOUNT FULL NAME OF LENDER ADDRESS
Name the Manager of the business for which this application is filed and state how he is compensated.
FULL NAME SOC. SEC. # RESIDENCE ADDRESS COMPENSATION
NOTE: Before signing this application, check all answers and explanations to see that you have answered all questions
fully and correctly. This application is to be executed under oath and subject to the penalties of false swearing and it
includes all attached sheets submitted herewith. Applicant understands that any license issued pursuant to this
application is conditioned upon the truth of the answers and statements made herein and that any false answers and
statements herein shall constitute cause for the suspension or revocation of any license issued pursuant to this application.
Should any change occur during the year for which a license is issued pursuant to this application which would require
a different answer to any question contained in this application, or any statement which is made a part of this application,
such change must be reported as an amendment to this application within thirty (30) days. The failure to make such
amendment shall be cause for the revocation of any license issued pursuant to this application.
STATE OF GEORGIA, OGLETHORPE COUNTY
I, _______________________________, applicant, do solemnly swear, subject to the penalties for false swearing, that the
statements and answers made by me to the foregoing questions in this application for a County License as a dealer in alcoholic
beverages are true and no false or fraudulent statement or answer is made herein to procure the granting of such license.
Further, I fully understand that any license granted pursuant to this application is a privilege and is revocable at the
discretion of the Board of Commissioners of Oglethorpe County.
Applicant's Signature (FULL NAME IN INK)
I hereby certify that
is personally known to me, that he
signed his name to the foregoing
application after stating to me that he knew and understood all statements and answers made herein, and, under oath
actually administered by me, has sworn that said statements and answers are true.
This _____________day of ______________ 20____.