Department of Alcoholic Beverage Control CORPORATE ...

1 Department of Alcoholic Beverage Control State of california Gavin newsom , governor CORPORATE questionnaire . Instructions: Complete all items. One officer must sign for the corporation. Item 16 - List Certificates chronologically, including active, canceled, and pending issuance. If stock is pledged, include date, number of shares, and from whom to whom. 1. NAME OF CORPORATION 2. ABC LICENSE NUMBER. 3. PREMISES ADDRESS 4. TELEPHONE NUMBER. 5. ATTORNEY'S NAME 6. ATTORNEY'S TELEPHONE NUMBER. 7. ATTORNEY'S ADDRESS. 8. NAME OF BANK ( CORPORATE account) 9. ACCOUNT NUMBER. 10. ADDRESS OF CORPORATE BANK ACCOUNT. 11. PERSONS AUTHORIZED TO SIGN ON BANK ACCOUNT (Print). 12. INCORPORATION DATE 13. STATE OF INCORPORATION 14. SECRETARY OF STATE FILE NUMBER. 15. OFFICERS AND DIRECTORS. TITLE NAME ADDRESS TELEPHONE NUMBER. TITLE NAME ADDRESS TELEPHONE NUMBER. TITLE NAME ADDRESS TELEPHONE NUMBER. TITLE NAME ADDRESS TELEPHONE NUMBER. TITLE NAME ADDRESS TELEPHONE NUMBER.

2 TITLE NAME ADDRESS TELEPHONE NUMBER. 16. LIST ALL STOCK CERTIFICATES. PERCENTAGE OF. CERTIFICATE NUMBER OUTSTANDING DATE DATE. TO WHOM ISSUED NUMBER OF SHARES SHARES OF STOCK ISSUED CANCELED. Continued on reverse I hereby certify the above are the present officers, directors and/or stockholders and that each such officer, director and stockholder is the real party in interest with respect to his/her position and is not acting directly or indirectly as an agent, employee or representative of any other person not reported to the Department . The provisions of sections 23405 and of the Business and Professions Code (B&P) are hereby acknowledged and it is understood that changes within the corporation and/or entities holding interest in the corporation will be reported to the Department as required by Rule CCR and a fee may be required pursuant to Sections & 24072 B&P. SIGNATURE (FOR THE CORPORATION) TITLE DATE SIGNED. ABC-243 (rev. 07/19). LIST ALL STOCK CERTIFICATES (Continued from other side).

3 PERCENTAGE OF. CERTIFICATE NUMBER OUTSTANDING DATE DATE. TO WHOM ISSUED NUMBER OF SHARES SHARES OF STOCK ISSUED CANCELED. ABC-243 (rev. 07/19).