Alcoholic Beverage Application Alcoholic Beverage Application This form is for businesses who are renewing existing alcoholic beverage license(s). Business Name* dba (if applicable) Site ID No. Name of Owner* First Last Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business Address (If different from mailing adress) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Cell PhoneEmail:* Is this business located within/adjacent to the Entertainment Destination Boundaries?* Yes No Licenses (Check all that apply)* Rectifier -- $750.00 Wholesaler -- $787.00 LP Quota Retail Package -- $472.00 LD Retail Drink -- $472.00 NQ1 Retail Drink (convention center) -- $1,100.00 NQ2 Retail Drink (restaurant, motel, EDC) -- $550.00 NQ3 Retail Drink (private club) -- $275.00 NQ4 Malt beverage retail drink -- $78.00 NQ Malt beverage package -- $78.00 ($50 if purchased with NQ4) Extended hours -- $1,000.00 Caterer -- $450.00 Bottling house -- $1,000.00 Malt beverage brewer -- $500.00 Malt beverage distributor -- $157.00 Malt beverage microbrewery -- $500.00 Malt beverage on premises -- $100.00 Limited golf course -- $600.00 Limited restaurant -- $600.00 Distiller -- $500.00 Qualified historic site -- $550.00 Amount owed:* $Will pay by Check in person Check by mail Credit card in person Credit card by phone - 606-584-2718 Date MM slash DD slash YYYY Name & contact phone# of person submitting renewal Note to administrator:NameThis field is for validation purposes and should be left unchanged.
