Department of Alcoholic Beverage Control
State of California
Gavin Newsom, Governor
APPLICATION QUESTIONNAIRE
Please read instructions, which includes Privacy Notice, before completing form.
1. APPLICANT'S NAME(S) (If an individual, first name, middle name, last name. Name of entity if corporation, limited partnership or limited liability company.)
P-12 LICENSEE
Yes No
(If yes, complete form ABC-811)
2. LICENSE TYPE(S) (Check appropriate items)
20 Off-Sale Beer & Wine
21 Off-Sale General
40 On-Sale Beer
41 On-Sale Beer & Wine Eating Place
42 On-Sale Beer & Wine Public Premises
47 On-Sale General Eating Place
48 On-Sale General Public Premises
Other
3. TRANSACTION TYPE (Check appropriate item)
Original (New)
Person-to-Person Transfer (check appropriate section):
Section 24071 (Surviving spouse, corporations, fiduciaries, etc.)
Section 24071.1 (Corporate Stock/Limited Partnership)
Section 24071.2 (Limited Liability Company)
Premises-to-Premises Transfer
Exchange
Other
4. TEMPORARY PERMIT REQUESTED (Person-to-Person transfers only)
Yes No
5. PREMISES ADDRESS (Where license to be issued) (Street number and name, city, zip code) County
6. PREMISES TELEPHONE NUMBER 7. PREMISES ARE INSIDE CITY LIMITS
Yes No
8. BUSINESS NAME (DBA) YOU WILL USE
9. BUSINESS MAILING ADDRESS (Street number and name, city, state, zip code) 10. MAILING ADDRESS
Permanent Temporary
11. ABC LICENSE COST (Item #33a on reverse) 12. SUBTOTAL (Item #33f on reverse)
13. HAS THE APPLICANT(S) EVER BEEN
CONVICTED OF A FELONY?
Yes No
14. HAS THE APPLICANT(S) EVER VIOLATED ANY OF THE PROVISIONS OF THE ALCOHOLIC BEVERAGE CONTROL ACT OR REGULATIONS
OF THE DEPARTMENT PERTAINING TO THE ACT?
Yes No
15. IF YES TO ITEM 13 OR 14, PLEASE EXPLAIN
16. TRANSFEROR'S NAME (If an individual, last, first, middle. Name of entity if corporation, limited partnership or limited liability company.) 17. ABC LICENSE NUMBER
18. TRANSFEROR'S PREMISES ADDRESS (Where license is now issued) (Street number and name, city, zip code)
19. PREMISES UNDER CONSTRUCTION
Yes No
IF YES, LIST ESTIMATED COMPLETION DATE 20. FRANCHISE
Yes No
21. NAME OF PERSON WE MAY CONTACT (For the applicant) 22. TITLE OF CONTACT PERSON
23. CONTACT TELEPHONE NUMBER 24. CONTACT E-MAIL ADDRESS
25. PREMISES IS CURRENTLY LICENSED
Yes No
IF YES, TYPE OF LICENSE 26. CURRENT LICENSE IS OPERATING
Yes No
IF NO, DATE CLOSED
FINANCIAL INFORMATION
27. ESCROW COMPANY'S NAME ESCROW COMPANY'S ADDRESS TELEPHONE NUMBER
28. BOOKKEEPER/ACCOUNTANT'S NAME BOOKKEEPER/ACCOUNTANT'S ADDRESS TELEPHONE NUMBER
29. LANDLORD'S NAME LANDLORD'S ADDRESS TELEPHONE NUMBER
30. MONTHLY RENT 31. LEASE EXPIRATION DATE 32. INDICATE WHETHER LEASE OR RENTAL AGREEMENT INCLUDES FURNITURE OR FIXTURES
All Some None
ABC-217 (rev. 01/19)
