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<br />DEPARTMENT OF LIQUOR CONTROL COUNTY OF HAWAI‘I <br />Hilo Lagoon Centre, 101 Aupuni St., Unit 230, Hilo, Hawai‘i 96720 * Phone: (808)961-8218 * Fax: (808)961-8684 <br />E-Mail: cohdlc@co.hawaii.hi.us <br />LIMITED LIABILITY COMPANY <br />(Applicable to application for original or transfer of liquor license or change to membership) <br />Name of Limited Liability Company: <br />Trade Name (dba): <br />Date of Organization: State: Date Registered State of Hawai‘i: <br />Attorney or Authorized Representative: Phone: <br />Address: Fax: E-mail: <br />CURRENT MEMBERS OF LLC <br /> Name Address <br /> <br />PROPOSED CHANGES TO LLC <br />Withdrawal: List Name(s) of Members (Attach State of Hawai‘i DCCA Statement of Dissolution) <br /> Admission (Attach personal history form for new member and State of Hawai‘i DCCA registration) <br />Member Address <br /> <br />SPECIAL INSTRUCTIONS: <br /> Agent’s name, address, telephone, fax who shall be responsible for the following: <br />A. Department Communications (Applications, Renewals, Financial, Notice of Hearing, etc.) <br /> <br />B. Service of Process (within State of Hawai‘i): <br /> <br />I certify that the above information is true and correct and that each member is the real party in interest of the Limited <br />Liability Company and is not disqualified from holding the license individually pursuant to §281-45, HRS. <br />Authorized Signature Date <br />Print Name <br />Hawai‘i County is an Equal Opportunity Provider and Employer <br />