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2. BEER & WINE BUSINESS LICENSE APPLICATION
3. Application Date
   Application Date
5. Type of Application*

   1. New Application
   2. Renewal Application
6. Is a copy of your ABC Permit attached?

   1. YES
   2. NO
7. Does your business have a valid City of Durham Privilege License?

   1. YES
   2. NO
11. Check all that apply

    1. Beer On-Premise

    1. Beer Off-Premise

    1. Wine On-Premise

    1. Wine Off-Premise
13. This application is for the sale of beer and/or wine at retail. The undersigned applicant for license to sell beer and/or wine states that the answers to the following questions are true of his/her own knowledge and are made for the purpose of inducing the City Council of the City of Durham to issue a license to the undersigned for the sale of such alcoholic beverages as indicated within the corporate limits of the City of Durham.
15. BUSINESS INFORMATION
17. Corporation Name or Business Owner's Name
    Include DBA if applicable
18. Email Address
20. Federal Tax Identification Number
21. North Carolina Alcoholic Beverage Control Commission Retail Permit Number
23. Physical Address of Business
    Include any suite or apartment #. DO NOT use a PO Box.
25. Mailing Address
27. Business Location Phone Number
28. Cell Phone Number
29. Fax Number
31. BUSINESS OWNER'S INFORMATION
33. Full Name of Owner(s)
34. North Carolina Driver's License Number
36. Home Address
38. Home Phone Number
39. Business Phone Number
40. Business Fax Number
41. Cell Phone Number
43. Email Address
44. Length of Residence
    In North Carolina (Years)
46. Are you a citizen of the United States?

    1. YES

    1. NO
47. How long have you operated this business?
    (Years)
49. Have you ever been convicted of a felony or crime involving moral turpitude?

    1. YES

    1. NO
51. Have you ever been convicted of violating the Federal or State prohibition laws?

    1. YES

    1. NO
52. If YES, were you convicted at any time within the past two years?

    1. YES

    1. NO
54. Did you complete serving a sentence for any such violation during the past two years?

    1. YES

    1. NO
55. Have you had any license to sell alcoholic beverages revoked during the past five years?

    1. YES

    1. NO
57. If you had your license revoked in the last five years, when and why was the license revoked?
    Provide as much detail as possible
59. As the present owner of this business, do you intend to operate this business yourself?

    1. YES

    1. NO
60. As the present owner of this business, do you intend to operate this business under your immediate supervision and direction?

    1. YES

    1. NO
62. To your knowledge, have any of the persons named in this application been convicted of any felony or crime involving moral turpitude, or of violation of the State or Federal Prohibition Laws?

    1. YES

    1. NO
64. BUSINESS MANAGER or OPERATOR OF BUSINESS
66. Full Name
67. North Carolina Driver's License Number
69. PREVIOUS OWNER of BUSINESS INFORMATION
71. Full Name
72. Phone Number
74. Address
76. OWNER of PREMISES
78. Full Name
79. Phone Number
81. Address
83. REFERENCES
    Names and contact information of individuals whom you are not associated with in business.
85. NAME/ADDRESS/PHONE NUMBER
87. NAME/ADDRESS/PHONE NUMBER
89. NAME/ADDRESS/PHONE NUMBER
91. As a further inducement to the City Council of the City of Durham, the owner agrees that he/she will promptly report any change or condition that may affect the validity of the information provided above.
93. ELECTRONIC SIGNATURE AGREEMENT
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
95. I agree with the Electronic Signature Agreement*

    1. YES
    2. NO
97. Digital Signature
    Person making application
98. PRINT NAME
    Person making application
99. Relationship to Business
101. Upload Attachments
Leave This Blank:


103. 1. Receive an email copy of this form.
104. Email address

     This field is not part of the form submission.

105. Submit Submit and Print

* indicates a required field