HomeMy WebLinkAboutForm - Add-Delete Officers or DirectorsRev. 02/18/2022
COUNTY OF HAWAI‘I – DEPARTMENT OF LIQUOR CONTROL 101 Aupuni Street, Unit 230, Hilo, Hawai‘i 96720 TEL: (808) 961-8218 FAX: (808) 961-8684
EMAIL: COHDLC@hawaiicounty.gov
ADD OR DELETE OFFICERS/DIRECTORS CORPORATION ONLY
HRS Section 281-41, Rule 4-6
Date: Liquor License #:
Licensee Name: Trade Name (Doing Business As)
Class: Kind:
(Dispenser, Retail, etc.) (Beer, Wine, General)
Premise Address:
Phone: Fax: Email:
Changes to Officers/Directors as follows (attach additional sheets, if necessary): Add Delete Effective Date of Change Name of Officer/Director Title(s) % of Ownership
I certify that all Officers/Director listed above are at least 21 years of age.
INITIAL
SIGNATURE of Licensee (Owner)/Authorized Agent DATE
PRINT NAME of Licensee (Owner)/Authorized Agent)
Note: If submission by Authorized Agent, please submit a Letter of Authorization signed by the Licensee/Owner.