HomeMy WebLinkAboutForm - Application for Liquor License - Original
DEPARTMENT OF LIQUOR CONTROL, COUNTY OF HAWAI’I
OFFICE USE ONLY
HILO LAGOON CENTRE, 101 AUPUNI STREET, UNIT 230,HILO, HAWAI'I 96720-4261
50.00
Filing Fee: $
PHONE: (808) 961-8218 FAX: (808) 961-8684 E-Mail: cohdlc@co.hawaii.hi.us
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____________ ____________
APPLICATION FOR LIQUOR LICENSE
Application No.
TO THE LIQUOR COMMISSION OF THE COUNTY OF HAWAI'I:
The undersigned hereby makes application for the following liquor license and makes the following statement:
CLASS: KIND: CATEG: ORY
1.Name of the applicant (company) is:
2.Applicant will do business under the name of:
3.Applicant’s mailing address is:
Telephone: FAX: E-mail:
4.The premises is located at:
_ ____________________________________________ TMK:_ _
5.Applicant is a/an: whose principal(s) are
(Individual, Corporation, Partnership, Limited Liability Company, Limited Partnership, Unincorporated Association)
NameTitle
6.That no person other than the Applicant named herein shall have any interest in the business or license affected
by this application without prior approval of such interest by the Liquor Commission and that no liquor license
issued to Applicant has been revoked within the term of two years preceding the date of this application.
7.I hereby certify that the above named applicant, principals and/or persons holding 25% more of stock are
twenty-one years of age or older and have not been convicted of a felony.
Signature
Print Name
Title
Date
STATE OF HAWAI'I )
) SS:
COUNTY OF HAWAI'I )
he/sheApplicant
, being first duly sworn, deposes and says that is the
he/shehe/she
herein named; that isauthorized to and does make this verification for and on its behalf; that has read
the foregoing application; and that the statements therein set forth are true.
Signature of Applicant before Notary
Subscribed and sworn to before me
this day of , 20. Doc. Date: # Pages:
Name: Circuit
Notary Public(signature)
Doc. Description
Notary Public (print name)
My commission expires.
Signature Date
NOTARY CERTIFICATION
The County of Hawai`i is an Equal Opportunity Provider and Employer