Form Application for Liquor Liability

LIQUOR LIABILITY QUESTIONNAIRE

Name Including DBA, and Address:

Name & Address of Liquor Permit/License Holder:

Date Liquor License First Obtained:

Type of License:

Type of Alcoholic Beverages Served/Sold: BeerWineLiquor

License Number:

Legal Drinking Age in Your State:

Name, Distance and Legal Drinking Age in Any State Within a 20 Mile Radius of your Establishment's Location:

State Distance Legal Age

Has the Applicant had any Warnings or Violations of State, County or City Liquor Control Laws?

If "Yes, Complete the Following:

Type of Warning/Violation:

Date of Warning/Violation:

Describe Fine or Suspension:

Do you Have any of the Following?

A: Ladies Night

B: Cover Charge

C: Live Band/DJ

D: Happy Hour

E: Entertainment Machines (Bucking Bronco, Surfboard, Etc.)

F: Connected to a Laundromat

G: Pool Table(s)

H: Dance Floor

I: Sports Facilities (Volleyball, Basketball, Etc)

J: Other Entertainment Facilities

Please Describe:

Do you "Card" Purchasers of Alcoholic Beverages?


Check all of Those who do the Carding:

Host/Hostess @ Door

Server/Waitress/Waiter

Bartender

Cashier


Annual Receipts from Sale of Alcoholic Beverages:

Annual Receipts from Sale of Food:

Hours of Operation:

Are you in close Proximity to a College?

Have your Employees Taken a Course in Alcohol Management Similar to the National Restaurant Association's "Fair Program" or "Alcohol Awareness Program"?

Insured's Signature:

(By typing your name, you are officially signing this form)

Date of Signature:

Print Name of Signer:

Agent / Broker Signature:

Date of Signature: