Schedule for Appointment of Agent by Corporation / Nonprofit Organization or Limited Liability Company

Schedule for Appointment of Agent by Corporation / Nonprofit Organization or Limited Liability Company

Submit to Municipal Clerk
All corporations/organizations or limited liability companies applying for a license to sell fermented malt beverages and/or intoxicating liquor must appoint an agent. The following questions must be answered by the agent. The appointment must be signed by an officer of the corporation/organization or one member/manager of a limited liability company and the recommendation made by the poper local official.
To the governing body of:*
The undersigned duly authorized officer/member/manager of:*
(registered Name of Corporation / Organization or Limited Liability Company)
A corporation/organization or limited liability company making application for an alcohol beverages license for a premises known as:*
(Trade Name)
Located at:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Appoints:*
(Name of Appointed Agent)
Home Address or Appointed Agent:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

To act for the corporation/organization/limited liability company with full authority and control of the premises and of all business relative to alcohol beverages conducted therein. Is applicant agent presently acting in the capacity or requesting approval for any corporation/organization/limited liability company having or applying for a beer and/or liquor license for any other location in Wisconsin?*

	Yes	No	If so, indicate the corporate name(s)/ liability company(ies) and municipality(ies).

Is applicant agent subject to completion of the responsible beverage server training course?*

YesNo
How long immediately prior to making this application has the applicant agent resided continuously in Wisconsin?
Place of residence last year:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
For:*
(Name of Corporation / Organization / Limited Liability Company)
Signature of Officer / Member / Manager

Clear
Any person who knowingly provides materially false information in an application for a license may be required to forfeit not more than $1,000.
ACCEPTANCE BY AGENT
I hereby accept this appointment as agent for the corporation/organization/limited liability company and assume full responsibility for the conduct of all business relative to alcohol beverages conducted on the premises for the corporation/organization/limited liability company.
Name of Agent:

First NameLast Name
Signature of Agent:

Clear
Date:

MonthDayYear
Agent's Age:
Date of Birth:

MonthDayYear
Date
Home Address of Agent:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
APPROVAL OF AGENT BY MUNICIPAL AUTHORITY

(clerk cannot sign on behalf of Municipal Official)
I hereby certify that I have checked municipal and state criminal records. To the best of my knowledge, with the available infomation, the character, record and reputation are satisfactory and I have no objection to the agent appointed.
Approved on:

MonthDayYear
Date
Signature of Proper Local Official:

Clear
Title:
(Town Chair, Village President, Police Chief)
Should be Empty: