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Application docu

  1. 1. • , . - (BOULDER COUNTY PUBLIC HEALTH Opport unit y fo r a n ea lt h y 1.8. Request for Retail Food Establishment License Thank you for notifying Boulder County Public Health (BCPH) about your plans to begin operation or change ownership of a retail food establishment, catering operation, or mobile unit. The following pages include a list of common items to be addressed before a retail food license can be issued. If you plan to extensively remodel the facility, change menu items, or change equipment a plan review may be required. "Extensively remodeled" is defined in Section 1.-202 (1.8) of the Colorado Retail Food Establishment Rules and Regulations and includes: • Increase in seating capacity by 20%. • Change or alteration made in the nonpublic areas that result in an increase/reduction of total space by 2s%or more. • Alteration that requires a building permit by local authorities. • Change that affects the facility's capability to handle food and utensils in a sanitary manner and create potentially hazardous conditions. If your plans meet this definition, please go to www.BoulderCountyFood.org and download the "Retail Food Facility Plan Review" packet or call our office at 303.441.1564 to request a plan review packet. BCPH's team is committed to providing excellence in technical assistance and customer service. Information about the requirements of operating a Retail Food Establishment can be found in the Colorado Retail Food Establishment Rules and Regulations, available on our website at www.BoulderCountyFood.org. Resources included in this packet: o Appendix A: Sample facility floor plan o Appendix B: Minimum requirements for retail food establishment license approval o Appendix C: Worksheet for Calculating Minimum Hot Water Requirements o Appendix D: Commissary Agreement (may need to submit if mobile unit, caterer, retail food processor) Please provide a copy of your menu and as much detail as possible about your operation. The information you provide will determine if your food handling techniques are consistent with proper food safety. It is important that proper food safety procedures are implemented from the start of operation since the majority offoodborne illness outbreaks are attributed to errors in food handling (e.g., improper cooling, reheating, etc.). Onsite wastewater treatment systems and non-community and private water supplies are permitted separately. For more information about these requirements contact Boulder County Public Health at 3°3.441.1564.
  2. 2. __ • r.-:-:-:::---=-===-::-:-:-=----------"...,..,.=:=--:-:-=-:-----j 20100 Tavern License (City) . . $500,00 1-2'~~---.:~~~'.E.----____~~~~~~=..!.!:E:~ 2011 0 Tavern License (County) ........ $500,00 20120 Manager Registration - Tavern . $ 75.00 Application Fee for New License Application Fee for New License· w/Concurrent Review .. " ....... 2310 0 Application Fee for Transfer ..... 19850 Resort Complex License (City) '''''''''''''' 19860 Resort Complex License (County) ......... " ........... " .". $500,00 19880 Add Related Facility to Resort Complex .. , $ 75,00 X__ Total _ 19900 Club License (City) ....... .. "",................ ,, .., $308.75 19910 Club License (County) .......................... $308.75 1905 0 Retail Gaming Tavern License (City) ..................... ,," .. $500.00 20200 Arts License (City) . $308.751906 0 Retail Gaming Tavern License (County) ................... $500.00 20210 Arts License (County) $308.751940 0 Retail Liquor Store License (City) . $227.50 20300 Racetrack License (City) .... $500.001941 0 Retail Liquor Store License (County). .. .. $312,50 20310 Racetrack License (County). " .............. $500.00 1950 0 Liquor Licensed Drugstore (City) ................".... $227.50 2040 0 Optional Premises License (City) .......... $500.001951 0 Liquor Licensed Drugstore (County) '" ......... $312.50 2041 0 Optional Premises License (County) ..... , $500.00 1960 0 Beer and Wine License (City)... ....... $351 .25 20450 Vintners Restaurant License (City) $750.00 1961 0 Beer and Wine License (County) ...... ".. .. .. $436.25 20460 Vintners Restaurant License (County) ...... $750,00 1970 0 Hotel and Restaurant License (City) .. $500.00 22200 Add Optional Premises to H & R .. .. $100.00 X__ Total . 1971 0 Hotel and Restaurant License (County) $500.00 23700 Master File Location Fee .. $ 25.00 X Total 1975 0 Brew Pub License (City) ................................, ... .. $750.00 23750 Master File Background ........ ..... " ...... " $25000 X- - Total ...­ 1976 0 Brew Pub License (County) .. . $750.00 1980 0 Hotel and Restaurant License w/opt premises (City) .... $500.00 1981 0 Hotel and Restaurant License w/opt premises (County) $500.00 1983 0 Manager Registration - H & R ..............................., ... $ 75.00 DR 8404 (05/07109) Page 1 COLORADO DEPARTMENT OF REVENUE 21 DEPARTMENT USE ONLY LIQUOR ENFORCEMENT DIVISION DENVER CO 80261 COLORADO LIQUOR RETAIL LICENSE APPLICATION D NEW LICENSE D TRANSFER OF OWNERSHIP D LICENSE RENEWAL ALL ANSWERS MUST BE PRINTED IN BLACK INK OR TYPEWRITIEN APPLICANT MUST CHECK THE APPROPRIATE BOX(ES) • LOCAL LICENSE FEE $ _________ APPUCANT SHOULD OBTAIN A COpy OF THE COLORADO UQUOR AND BEER CODE Call "n" ....,n "..,.-, 1. Applicant is applying as a D Individual D Corporation D Limited Liability Company D Partnership (includes Limited Liability and Husband and Wife Partnerships) D Association or Other County City Industry Type License Account Number Slate __-750 (999) City 2180-100 (999) 2300-100 (999) County 2190-100 (999) Managers Reg __-750 (999) $ •
  3. 3. DR 8404 (05/07109) Page 2 APPLICATION DOCUMENTS CHECKLIST AND WORKSHEET Instructions: This check list should be utilized to assist applicants with filing all required documents for licensure. All documents must be properly signed and correspond with the name of the applicant exactly. All documents must be typed or legibly printed. Upon final State approval the license will be mailed to the local licensing authority. Application fees are nonrefundable. ITEMS SUBMITTED, PLEASE CHECK ALL APPROPRIATE BOXES COMPLETED OR DOCUMENTS SUBMITTED I. APPLICANT INFORMATION D A. Applicant/Licensee identified. D B. State sales tax license number listed or applied for at time of application. D C. License type or other transaction identified. D D. Return originals to local authority D E. Additional information may be required by the local licensing authority. II. DIAGRAM OF THE PREMISES D A. No larger than 8 1/2" X 11 ". D B. Dimensions included (doesn't have to be to scale). Extenor areas should show control (fences, walls, etc.). D C Separate diagram for each floor (if multiple levels). D D. Kitchen - identified if Hotel and Restaurant. III. PROOF OF PROPERTY POSSESSION D A. Deed in name of the Applicant ONLY (or) D B. Lease in the name of the Applicant ONLY. D C. Lease Assignment in the name of the Applicant (ONLY) with proper consent from the Landlord and acceptance by the Applicant. D D. Other Agreement if not deed or lease. IV. BACKGROUND INFORMATION AND FINANCIAL DOCUMENTS D A. Individual History Record(s) (Form DR 8404-1). D B. Fingerprints taken and submitted to local authority. (State authority for master file applicants.) D C. Purchase agreement, stock transfer agreement, and or authorization to transfer license. D D. List of all notes and loans. V. CORPORATE APPLICANT INFORMATION (If Applicable) D A. Certificate of Incorporation (and/or) D B. Certificate of Good Standing if incorporated more than 2 years ago. D C. Certificate of Authorization if foreign corporation. D D. List of officers, directors and stockholders of parent corporation (designate 1 person as "principal officer") VI. PARTNERSHIP APPLICANT INFORMATION (If Applicable) D A. Partnership Agreement (general or limited) Not needed if husband and wife. VII. LIMITED LIABILITY COMPANY APPLICANT INFORMATION (If Applicable) D A. Copy of articles of organization (date stamped by Colorado Secretary of State's Office). D B. Copy of operating agreement. D c. Certificate of Authority (if foreign company). VIII. MANAGER REGISTRATION FOR HOTEL AND RESTAURANT, TAVERN LICENSES WHEN INCLUDED WITH THIS APPLICATION D A. $75.00 fee. D B. Individual History Record (DR 8404-1).
  4. 4. DR 8404 (05/07/09) Page 3 6. Is the applicant (including any of the partners, if a partnership; members or manager if a limited liability company; or officers, stock- Yes No holders or directors if a corporation) or manager under the age of twenty-one years? D D 7. Has the applicant (including any of the partners, if a partnership; members or manager if a limited liability company; or officers, stockholders or directors if a corporation) or manager ever (in Colorado or any other state); (a) been denied an alcohol beverage license? D D (b) had an alcohol beverage license suspended or revoked? D 0(c) had interest in another entity that had an alcohol beverage license suspended or revoked? D 0If you answered yes to 7a, b or c, explain in detail on a separate sheet. 8. Has a liquor license application (same license class), that was located within 500 feet of the proposed premises. been denied within the preceding two years? If "yes." explain in detail. D 0 9. Are the premises to be licensed within 500 feet of any public or private school that meets compulsory education requirements of Colorado law, or the principal campus of any college, university or seminary? D 0 10. Has a liquor or beer license ever been issued to the applicant (including any of the partners. if a partnership; members or manager if a limited liability company; or officers, stockholders or directors if a corporation)? If yes, identify the name of the business and list any current or former financial interest in said business including any loans to or from a licensee. 0 0 11. Does the Applicant, as listed on line 2 of this application, have legal possession of the premises by virtue of ownership, lease or other arrangement? 0 Ownership 0 Lease o Other (Explain in Detail) 0 D a. If leased, list name of landlord and tenant, and date of expiration, EXACTLY as they appear on the lease: ILandlord I Tenant IExpires I Attach a diagram and outline or designate the area to be licensed (including dimensions) which shows the bars, brewery, walls, partitions, entrances, exits and what each room shall be utilized for in this business. This diagram should be no larger than 8 1/2" X 11 ". (Doesn't have to be to scale) 12. Who, besides the owners listed in this application (including persons, firms, partnerships, corporations, limited liability companies), will loan or give money, inventory, furniture or equipment to or for use in this business; or who will receive money from this business. Attach a separate sheet if necessary. DATE OF BIRTH INTERESTNAME FEIN OR SSN Attach copies of all notes and security instruments, and any written agreement, or details of any oral agreement, by which any person (including partnerships, corporations, limited liability companies, etc.) will share in the profit or gross proceeds of this establishment, and any agreement relating to the business which is contingent or conditional in any way by volume, profit, sales. giving of advice or consultation. 13, Optional Premises or Hotel and Restaurant Licenses with Optional Premises Yes No Has a local ordinance or resolution authorizing optional premises been adopted? 0 0 Number of separate Optional Premises areas requested. (See License Fee Chart) 14. Liquor Licensed Drug Store applicants, answer the following : Yes No Pharmacy? COpy MUST BE ATTACHED. 0 0 (a) Does the applicant for a Liquor Licensed Drug Store have a license issued by the COlorado Board of 15. Club liquor License applicants answer the following and attach: Yes No(a) Is the applicant organization operated solely for a national. social, fraternal , patriotiC, political or athletiC purpose and not for pecuniary gain? 0 0 (b) Is the applicant organization a regularly chartered branch, lodge or chapter of a national organization which is operated solely for the object of a patriotiC or fraternal organization or society, but not for pecuniary gain? 0 0 (c) How long has the club been incorporated? (d) Has applicant occupied an establishment for three years (Three years required) that was operated solely for the reasons stated above? D D 16. Brew-Pub license or Vintner Restaurant Applicants answer the following: Yes No (a) Has the applicant received or applied for a Federal Permit? 0 0 (Copy of permit or application must be attached) 17a. Name of Manager (for all on-premises applicants) ___ _ (If this is an IDate of Birth application for a Hotel, Restaurant or Tavern License, the manager must also submit an Individual History Record (DR 8404-1). 17b. Does this manager act as the manager of, or have a financial interest in, any other liquor Yes No licensed establishment in the State of Colorado? If yes, provide name, type of license and account number. DO 18. Tax Distraint Information. Does the applicant or any other person listed on this application and including its partners, officers, directors, stockholders, members (LLC) or managing members (LLC) and any other persons with a 10% or greater financial interest Yes No in the applicant currently have an outstanding tax distraint issued to them by the Colorado Department of Revenue? 0 0 If yes, provide an explanation and include copies of any payment agreements.
  5. 5. DR 8404 (05/07109) Page 4 19. If applicant is a corporation, partnership, association or limited liability company, applicant must list ALL OFFICERS, DIRECTORS, GENERAL PARTNERS. AND MANAGING MEMBERS. In addition applicant must list any stockholders. partners, or members with OWNER­ SHIP OF 10% OR MORE IN THE APPLICANT. ALL PERSONS LISTED BELOW must also attach form DR 8404-1 (Individual History record), and submit finger print cards to their local licensing authority. NAME HOME ADDRESS, CITY & STATE DOB POSITION % OWNED' 'If total ownership percentage disclosed here does not total 100% applicant must check this box D Applicant aHirms that no individual other than these disclosed herein, owns 10% or more of the applicant Additional Documents to be submitted by type of entity D CORPORATION D Cert. of Incorp. D Cert. of Good Standing (if more than 2 yrs. old) D Cert. of Auth . (if a foreign corp.) D PARTNERSHIP D Partnership Agreement (General or Limited) D Husband and Wife partnership (no written agreement) D LIMITED LIABILITY COMPANY D Articles of Organization D Cert. of AuthOrity (if foreign company) D Operating Agrmt. D ASSOCIATION OR OTHER Attach copy of agreements creating association or relationship between the parties Registered Agent (if applicable) IAddress for Service OATH OF APPLICANT I declare under penalty of perjury in the second degree that this application and all attachments are true, correct, and complete to the best of my knowledge. I also acknowledge that it is my responsibility and the responsibility of my agents and employees to comply with the provisions of the Colorado Liquor or Beer Code which affect my license. Authorized Signature ITitle IDate REPORT AND APPROVAL OF LOCAL LICENSING AUTHORITY (CITY/COUNTY) Date application flied with local authority Date of local authority hearing (for new license applicants; cannot be less than 30 days from date of application 12-47-311 (1» C.R.S. THE LOCAL LICENSING AUTHORITY HEREBY AFFIRMS: That each person required to file DR 8404-1 (Individual History Record) has: Yes No o Been fingerprinted .. .......... .. .... .. ................ ... ......... .......... " ..,," ............... ..... .. ............... , ....... ....... .. ..... ...... . ... ..•.... .... .. . .. ...... 0 0 o Been subject to background investigation, including NCIC/CCIC check for outstanding warrants .. ...... ..... .............. 0 0 That the local authority has conducted, or intends to conduct, an inspection of the proposed premises to ensure that the applicant is in compliance with, and aware of, liquor code provisions aHecting their class of license ." .... ...................... 0 0 (Check One) 0 Date of Inspection or Anticipated Date 0 Upon approval of state licensing authority. The foregoing application has been examined; and the premises, business to be conducted , and character of the applicant are satisfactory. We do report that such license, if granted, will meet the reasonable requiremems of the neighborhood and the desires of the adult inhabitants, and will comply with the provisions of Title 12, Article 46 or 47, C.R.8 THEREFORE, THIS APPLICATION IS APPROVED_ Local Licensing Authority for I Telephone Number 0 TOWN , CITY 0 COUNTY Signature Title Date Signature (attest) Title Date
  6. 6. OMB Approval No. 3245-0016 Expiriltion Dilte: II 13UI2U 12 U. S. Small Business Administration APPLICATION FOR BUSINESS LOAN IndivIdual I Full Address Name of Applicant Business Tax LD No. or SSN Full Street Address of'Business Tel. No. (inc. Area Code) Llty I County I State LIp Number of Employees (including subsidiaries and artiliates) At Time of Application - - ­ Jf Loan )S Approved - - - SubsidIaries or AffIliates - - ­ (Separate for above) Type of' Business Date Business Established Bank of Business Account and Address Use of Proceeds: (Enter Gross Dollar Amounts Rounded to the Nearest Hundreds) Loan Requested Loan Request Land Acquisition Pay otrSBA Loan New Construction! Expansion Repair Pay otrBank. Loan (Non SBA Associated)* Acquisition and/or Repair of Machinery and Equipment Other Debt Payment (Non SBA Associated) Inventory Purchase All Other Working Capital (including Accounts Payable) Total Loan Requested Acquisition of Existing Business Term of' Loan - (Requested Maturity) Yrs. CURRENT AND PREVIOUS SBA AND OTHER GOVERNMENT DEBT: Complete the chart below if you, your business, any principal of your business, any atliliate of your business, any other business currently owned by a principal, or any business previously owned by you or a principal of your business has received or applied for any direct or guaranteed financial assistance from the Federal Government, including student loans and disaster loans. All current previQus and pending Government debt must be listed including loans that have been paid in full or those that resulted in a loss to the Government. (Note: Loans that resulted in a loss to the Government include loans that were charged off, compromised, or discharged as a result of bankruptcy. The amount of the loss is the outstanding principal balance of the loan that the Government had to write off after all collection activities (including compromise) were finalized.) Name of'Agency Borrower's Name Original Amount of Loan Date of' Application Loan Status Outstanding Balance $ Amount of Loss to the Government. Agency Loan # 1. $ $ $ # 2. $ $ $ # 3. $ $ $ # 4. $ $ $ # ASSISTANCE: Did you commit to pay -- or have you paid -- anyone (including the lender) to assist you in either obtaining this loan (such as a broker, consultant or relerral agent) or in preparing the application or application materials lor this loan (such as a loan packager)? Yes 0 No 0 If "yes," complete SBA Form 159 (7a) - (Fee Disclosure Form and Compensation Agreement) for each [!l!rty that was [laid or will bt l!aid.) Note: The estimated burden completing this form is 12.0 hours per response. You will not be required to respond to collection of information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to the U.S. Small Business Administration, Chief, AlB, 409 3'd St, SW, Washington, DC. 20416 and Desk Office for Small Business Administration, Office of Management and Budget, New Executive Building, room 10202 Washington, D.C. 20503 . OMB Approval (3245-0016) PLEASE DO NOT SEND FORMS TO OMB. SUBMIT COMPLETED APPLICATION TO LENDER OF CHOICE. • .. SBA Form 4 (9-09) Previous Edition Obsolct~ Page l
  7. 7. ALL EXHIBITS MUST BE SIGNED AND DATED BY PERSON SIGNING THIS FORM BUSINESS INDEBTEDNESS: Furnish the followmg infonnation on all outstanding installment debts, contracts, notes, and mortgages payable. Indicate by an asterisk (0) items to be paid by loan proceeds and reasons lor paying them. (Present balance should agree with the latest balance sheet submitted) To Whom Payable Original Amount Origmal Date Present Balance Rate of Interest Maturity Date Monthly Payment Secunty Current or Past Due Acc!. # $ $ $ Ace!. # $ $ $ Aecl. # $ $ $ Acc!. # $ $ $ Acct. # $ $ $ •MANAGEMENT (PropnelOr, partners, officers, directors, all holders of outstanding stock -100% of ownershi[l must be shown.) Use separate sheet if necessary. Name and Social Security Number Positionrritle Complete Address % Owned 'Gender 'Veteran Status Veteran Yes[]NoO If yes, service-disabled?YesDNoL Race • Amer Indian or Alaska Nalive 0 ASlanO Black or African-Amet. 0 Native Haw. or Pacific lslanderO White 0 *Ethniciry:Hispanic or LatinoO Not Hisp or Lantino[] L-Race;' :Amer. Indian or Alaska Native[] AsianOBlack or African-AmeLO Native Haw or Pacilic Islander0 WhiteD 'Veteran SUltus 1! Veteran YesON0B fyes, servlce-d l sabled?YespN_~ O ___ - 'Etbnicity:Hlspanic or LatinoO Not Hisp or LantinoO 'Veteran Status Veteran Yes[]No f yes, serVice-disabled? YeUNo Race;' :Amer. Indian or Alaska NativeO AsianOBlack or African-AmeLONative Haw. or PaCific IslanderO WhiteD 'Ethniciry:Hispanic or Latino 0 Not Hisp or Lantino 0 'Veteran Status lV.eteran Yes[]NoO fyes, service-disabled?Yes[]No Race;' :Amer. Indian or Alaska Native 0 ASlanOBlack or African-Amer.O Native Haw or Pacific Islander 0 WhiteD *Ethnicity:Hlspanic or Latino 0 Not Hisp or Lantino 0 *This data is collected for statistical purposes only. It has no bearing on the credit deCision. Disclosure is voluntary. One or more boxes for race may be seIected Also, include the tax i.d. number [EIN or Social Security Number -or Guaranty Loans please provide an original and one copy (Photocopy (SSN)l Label it [xhibit B. 's Acceptable) of the Application Form and all Exhibits to the participating Lender. For Direct Loans submit one original copy 4. Include the financial statements listed below: a, b, c lor the last pl'the application and Exhibits to SBA . three years; also a, b, c, and d as ol'the same date, - current within I.Submit SBA Form 912 (Statement of Personal History) lor each 90 days of tiling the application; and statement e. if applicable. All information must be signed and daled (a) Balance Sheet; (b) Profit proprietor (ifsole proprietorship), partner (if a partnership), and by each and Loss Statement (if not avai lable, explain why and substitute pflicer, director, and owner 01'20% or more of the company's stock (if a federal income tax forms); (c) Reconciliation of Net Worth; (d) 'orporation, limited liability company or development company). Aging of Accounts Receivable and and Payable (summary); (e) 7. If your collateral consists oC(A) Land and Building, (B) Machinery Projection of earnings for at least onc year where linancial and Equipment, (C) furniture and fixtures, (D) Accounts Receivable, statcments for the last three years are unavailable or when SBA E) Inventory, (F) Other, please provide an itemized list that contains requests them, Label it Exhibit C. (Contact SBA for a referral if erial and identification numbers for all articles that had an original value assistance with preparation is wanted.) of greater than $5,000. Include a legal description of Real Estate oIH:red as collateral. l ,abel it Exhibit A. 5. Provide a brief history of your company and a paragraph describing the expected benefits it will receive from the loan. Label 3. Furnish a signed current personal balance sheet (SBA Form 413 it F.xhibit D. may be used tor this purpose) lor (I) each proprietor; or (2) each limited 6. Provide a brief description similar to a resume of the education, partner who owns 20% or more interest and each gcneral partner; or (3) technical and business background tor all the people listed under each stockholder owning 20% or more of voting stock. Include the Management. Label it Exhibit L assets and liabilities of the spouse and any minor children. SBA corm 4 (9-09) Previous Edition Obsolete ra~e 2
  8. 8. 7. Submit the name, addresses, tax I.D. number (EIN or SSN), and current persunal linancial statement of any co-signers whu are not utherwise affiliated with the business and any guarantors for the loan nut. covered hy 3. abuve. Exhibit F. 8. Include a list or any machinery or equipment or other non-real estate assets to be purchased with luan proceeds and the cost of each item as quoted by the seller. Include the seller's name and address. Exhibit G. 9. Have you or any oJJicer oryour company ever been invulved in bankruptcy or insolvency proceedings') [ ]Yes [ JNo. If yes, please provide the details as Exhibit H. 10. Are you ur yuur business involved in any pending lawsuits? [ ]Yes [ JNo. If yes, provide the details as Exhibit I. 11.00 you or yuur spuuse or any member ufyour househuld, ur anyone whu owns, manages, or directs yuur business or their spouses ur members uf their huuseholds work for the Small Business Administration, Small Business Advisory Council, SCORE or ACE, any Federal Agency, ur the participating lender? [ ]Yes I INo. Iryes, please provide the name and address uf the person and the otTIce where employed. I.abel this Exhibit J. 12. Does your business, its owners or majority stockholders own or have a controlling interest in other businesses? I ]Yes [ ]No. If yes, please provide their names and the relationship with your company along with financial data requested in question 4. Label this Exhibit K. 13. Do you buy from, sell to, or use the services of any concern in which someone in yuur cumpany has a significant financial interest') I ]Yes [ ]No. If yes, provide details on a separate sheet uf paper. Exhibit k 14. Is your business is a Iranchise, [ ]Yes [ ]No. Iryes, include a copy of the tranchise agreement and a eupy of the FTC disclosure statement supplied to you by the Franchisor. Label this Exhibit M. CONSTRUCTION LOANS ONLY AGREEMENTS AND CERTIFICATIONS AGREEMENTS: By signing below you agree to the following: (a) A reements of non-em 10 menl of SBA Personnel. I agrec that if SBA approves this application I will not, for at least two years, hire as an employee or consultant anyone that was employed by the SBA during the one year period prior to the loan disbursement. (b) Waiver of Claims. As consideration for any Management, Technical, and/or Business Developmenl Assistance that may be provided, I waive all claims against SBA and ils consultants. (c) Criminal Background. I authorize the SBA's Oftice uf'lnspector General to requesl criminal record informatiun about me from crim inal justice agencies for the purpuse uf determining my eligibility tor assistance under the Small Business Act. (d) Reimbursement uf EXQ!..!li~. I agree 10 pay for ur reimburse SBA lor the cust uf any surveys, title or mortgage examinations, appraisals, credil reports, etc., performed by non-SBA personnel provided I have given my cunsent. (e) Reporting. I agree to repurt tu the SBA Office oflhe Inspeclor General, Washington. DC 20416 any federal guvernment employee whu uffers, in relurn for any type of compensalion, 10 help get this loan appruvt:d. READ THE FOLLOWING CAREFULLY If you knowingly make a false statement, you can be fined up to $250,000 and/or imprisoned for not more than five years under J8 USC 1001; if submitted to a Federally insured institutiun, under 18 USC 1014 by Imprisunment ufnut mUre than twenty years and/or a fine of not more than $1,000,000 15. Include as a separate exhibit the estimated cost of the pruject and a statement of the suurce of any additional funds. lo' I hi 'xhi 't 16. Pruvide copies of preliminary construction plans and specificatiuns. Labellhis as Exhibit O. Final plans will be required prior to disbursement. EXPORT LOANS 17. Does your business currently expurt, ur will it start exporting, pursuant to this loan (if approved) ') Check here: I JYes I )No 18. If you answered yes to item 17, what is your estimate of the total export sales this loan would support? $ 19. Wuuld you like informatiun on Expurting? Check here: [ JYes I ]No COUNSELING/TRArNING 20. Have you received counseling or training from SBA (e.g., SCORE, ACE, SBDC, WBC, etc.) 'J Check here: [ ]Yes [ ]No SUBMIT COMPLETED APPLICATION TO L~ND~R OF CHOICE. CERTIFICATIONS: By signing beluw yuu certify as 10 tht: following: (a) All informatiun in this Application and the Exhibits is true and cumplete tu the best ufyuur knowledge. You undersland Ihat Ihis inlormatiun is being submiued tu a lender and SBA so Ihey can decide 10 make a loan or give a luan guaranty, and Ihalthe lender and SBA are relying un Ihis infurmation. (b) You have nol paid anyone employed by the Federal Government for help in gt:tting this luan. Yuu understand that yuu do not need to pay any olher third-party for assistance in locating a knder or preparing this Application or Exhibits, and you certify that you will disclose all parties that were paid fur such assistance to the Lender and will complete the SBA Form 159 for all such persons. (c) I have read a copy of the "Slatements Required By Law And Executive Order," which is auached to this application and agree to cumply with the reljuiremcnts in this Notice. If Applicant is a proprietor or general partner, sign helow. By: If Applicant is a Corporation, sign below: Corporate Name and Seal Dale By: Signature urPresidenl AUested by: Signature uf Corporate Secrt:tary SBA porm 4 (9-09) Provious Edilion Obsolele Page 3
  9. 9. Other than the person that signed on page 3, each Pa11ner, each Stockholder owning 20% or more, and each Guarantor must sign below. In addition, if a husband and wife collectively own 20% or more of a company, each spouse must also sign. No one should sign more than once. Business Name: _____________________ _______________ APPLICANT'S CERTIFICATION READ THE FOLLOWING CAREFULLY -- FALSE STATEMENTS ARE SUBJECT TO CRIMINAL PROSECUTION: If you knowingly make a false statement, you can be fined up to $250,000 and/or imprisoned for not more than five years under 18 USC 1001; if submitted to a Federally insured institution, under 18 lISC 1014 by Imprisonment of not more than twenty years and/or a fine of not more than $1,000,000 By signing below you certify as to the following: (a) You have reviewed (I) the responses to the question about debt on page I of the application; (2) the responses to questions II, 12, and 13 (application-page 3), and (3) any financial statement that)'Ql! were required to complete as Exhibit B or r to the application and certii)' that as to you personally all information in this Application and Financial Statement is true and complete to the best of your knowledge. You acknowledge that this information is being submitted to a lender and SBA so they can decide to make a loan or give a loan guaranty, and that the lender and SBA are relying on this in1ormation. (b) You have read a copy orthe "Statements Required By Law And Executive Order," which is attached to this application and agree to comply with the requirements in this Notice. Signature Date Check all that apply: [ ] guarantor r ]owner-indicate percentage owned: r ] [ ]partner-indicate whether [ ] general or [ ] limited Signature Date Check all that apply: [ 1guarantor l .I owner-indicate percentage owned: l J l Jpartner-indicate whether r ]general or [ ] limited Signature Date Check all that apply: [ ] guarantor [ 1owner-indicate percentage owned: [ 1 [ 1partner-indicate whether [ 1general or l J limited Signature Date Check all that apply: l 1guarantor [ ] owner-indicate percentage owned: [ J [ 1partner-indicate whether [ ] general or [ ] limited Signature Date Check all that apply: [ ] guarantor l J owner-indicate percentage owned: [ J [ ] partner-indicate whether [ Jgeneral or l Jlimited Signature Date Check all that apply: [ ] guarantor [ ] owner-indicate percentage owned: [ 1 [ 1partner-indicate whether l ]general or [ ] limited Signature Date Check all that apply: l ]guarantor [ ] owner-indicate percentage owned: l J [ ]partner-indicatc whether [ 1general or [ llimited SBA Form 4 (9-09) Previous Edition Obsolete Page 4

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