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