STATE OF TENNESSEE COUNTY OF LOUDON COUNTY

ON-PREMISES PERMIT ________                                              MAP NO. __________________
OFF-PREMISES PERMIT _______                                              PARCEL NO.________________
ON- AND OFF- PREMISES PERMIT________                          BOARD MEETING
MANUFACTURER'S OR  DISTRIBUTOR'S PERMIT ______   DATE _____________________ SPECIAL EVENTS PERMIT _____

I HEREBY MAKE APPLICATION FOR A PERMIT TO SELL, STORE, MANUFACTURE, OR DISTRIBUTE BEER OR OTHER BEVERAGES AUTHORIZED TO BE SOLD, STORED, MANUFACTURED OR DISTRIBUTED UNDER THE PROVISIONS OF TENNESSEE CODE ANNOTATED �� 57-5-101 et seq., AND BASE MY APPLICATION UPON THE ANSWERS TO THE FOLLOWING QUESTIONS:

1. Full name of applicant (owner of business) _________________________________________

2. Type of applicant (check one): Person_____ Firm______ Corporation_____ Joint-stock
Company_____ Syndicate_____ Association_____

3. Give the name and address of all persons, firms, corporations, joint-stock companies, syndicates or associations having who own 5% or more of the business (attach additional sheet, if needed)____________________________________________________________________

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If the owner is an individual, answer questions 4, 5 and 6. Otherwise, proceed to question 7.

4. What is your present home address? ______________________________________________
5. Previous address(es) within the last ten years (use additional sheet if necessary) ___________

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6. Date of birth ____________________________ Home telephone _______________________

7. Applicant's business telephone ______________________________________

8. Under what name will this business operate? _______________________________________

9. Give business address and geographical location_____________________________________

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10. Describe the nature of the business you will operate _________________________________

11. Name and address of person to receive annual tax notices and any other communication ___

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12. Name and address of property owner (if other than business owner) ____________________

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13. Will this permit be used to operate two or more restaurants or other businesses within the same building? (yes or no)______ . If yes, specify number ______ , and list the names of all restaurants or other businesses and describe all locations (use separate sheet if necessary) _____

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14. Give the name, date of birth, and address of any manager other than the applicant ________

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15. Has any person who owns five percent (5%) or more of the business, any manager listed in response to question 14 above, or any other employee of the business, been convicted of any violation of the beer or alcoholic beverage laws or any crime (other than minor traffic violations) within the past ten (10) years?_____ If yes, give the particulars of each charge, the court, and the date convicted _________________________________________________________________

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16. Have you, your business, or any person who owns five percent (5%) or more of the business, ever had a beer permit revoked, suspended or denied in the State of Tennessee ______ If yes, specify where, when and why______________________________________________________

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17. Give the name, relationship to the applicant (if applicable) and address of the former beer permittee at this location_________________________________________________________

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Loudon County has adopted a rule forbidding the sale, storage or manufacture of beer within 2,000 feet of a church, school, daycare, cemetery, or other place of public gathering. 18. Give the name and address of the church or other place of worship nearest to your business?

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19. Give the name and address of the school nearest to your business? _____________________

Loudon County has adopted a rule forbidding the sale, storage or manufacture of beer or like beverages within 300 feet of a residential dwelling, if the owner objects to the issuance of a beer permit. 20. Give the name of the owner and the address of the nearest residential dwelling to your business ______________________________________________________________________

_____________________________________________________________________________ I CERTIFY THAT THIS APPLICATION CONTAINS TRUE INFORMATION TO THE BEST OF MY KNOWLEDGE AND BELIEF. I AM AWARE OF MY CONTINUING OBLIGATION TO AMEND OR SUPPLEMENT THIS APPLICATION PROMPTLY IF A CHANGE IN CIRCUMSTANCES AFFECTS THE RESPONSES PROVIDED IN THIS APPLICATION, EITHER BEFORE OR AFTER A PERMIT HAS BEEN ISSUED. I CERTIFY THAT I AM KNOWLEDGEABLE OF THE LAWS PROHIBITING THE SALE OF BEER TO MINORS. I AM AWARE THAT I WILL NOT BE ISSUED A BEER PERMIT OR MY PERMIT WILL BE REVOKED IF MY BUSINESS LOCATION CAUSES TRAFFIC CONGESTION OR INTERFERES WITH SCHOOLS, CHURCHES, OR OTHER PLACES OF PUBLIC GATHERING, OR OTHERWISE INTERFERES WITH PUBLIC HEALTH, SAFETY AND MORALS. I WILL SURRENDER TO THE BEER BOARD ANY PERMIT ISSUED UNDER THIS APPLICATION WITHIN FIFTEEN (15) DAYS OF TERMINATION OF THE BUSINESS, CHANGE IN OWNERSHIP, RELOCATION OF THE BUSINESS, OR CHANGE OF THE BUSINESS'S NAME. ___________________________________________
Signature of Applicant/Owner (or authorized officer) Sworn to and subscribed before me this______ day of ________________ , 19_____ . ______________________________ Notary Public My Commission Expires: ____________________ NOTICE: A non-refundable $250.00 fee must accompany this application. If the application is approved, you are required to provide documentation of sales tax registration to the county within ten (10) days of approval. An annual privilege tax of $100.00 is imposed on the business of selling, distributing, storing or manufacturing beer in this state. The tax is due each January 1 and is payable to the County Clerk. This tax is prorated for new permits issued after January 1, and must be paid when the permit is issued. ANY APPLICANT MAKING A FALSE STATEMENT IN THIS APPLICATION SHALL FORFEIT HIS OR HER PERMIT AND SHALL NOT BE ELIGIBLE TO RECEIVE ANY PERMIT FOR TEN (10) YEARS.