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Alcohol License REQUIRED INFORMATION ACKNOWLEDGEMENT
Applications must be returned COMPLETE with attachments and supporting documentation. Please check your submission for the following:
Initial each item acknowledging that the required item is included in your packet.

________________	Completed Application and Personnel Statement Signed and Sealed
________________	All applicable license fees.
________________	Fingerprint Cards and Background Check for Registered Agent.
________________	If NEW Business, provide a Completed Occupational Tax Return.
________________	Completed Affidavit (OCGA 50-36-1e2 Affidavit) & Verifiable Document
________________	Completed Private Employer Affidavit
________________	Copy of Food Health Permit
________________	Detailed sketch of completed building and outside premises.*
________________	Proposed plans, specifications and copy of Building Permit.*
________________	Evidence of ownership of building or a copy of the Lease Agreement.
________________	Copy of Note(s)/Evidence of Indebtedness.
________________	Passport-size photograph (front view) from within the last two years.
________________	Other information: ______________________________________________________________________

Notes:
*If requesting a "Package Sales" license, also provide a scale drawing showing distances to any nearby Churches, Schools or Rehab Center. Or furnish certificate of Registered Surveyor that location complies with Ordinances.
OFFICE USE ONLY
Reviewed By: ____________________________________________ Date: _________________________________ Agent for Board of Commissioners
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License Requested

Business//Manager Information

BUSINESS REQUESTING LICENSE
Business Name
Address
City
State
Zip Code
APPLICANT
Applicant's Name
If it is a Corporation/Partnership enter the Name and Address of Registered Agent.
Address
City
State
Zip Code
MANAGER
Manager's Name
Address
City
State
Zip Code
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Interested Parties

INTERESTED PARTIES
Is there a Person, Form or Corporation that has a percent interest in the business?
1. Yes
1. No
If so, list the Name, Business Address, and Percent of Interest for each person, firm or corporation having any interest in this business.
Name
Percent of Interest
Business Address
City
State
Zip Code
Do you have any additional persons, firms or corporations to add?
1. Yes
1. No
Name
Percent of Interest
Business Address
City
State
Zip Code
If a corporation holds an interest in this business, list the name, position held, address and percent interest for each officer and board member of each corporation.
Name
Percent of Interest
Position Held
Business Address
City
State
Zip Code
Do you have any additional Officers or Board Members to add?
1. Yes
1. No
Name
Percent of Interest
Position Held
Business Address
City
State
Zip Code
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Building/Property Information

BUILDING/PROPERTY INFORMATION
Name(s) and Address(es) of Owner(s) of Building and Property
Owner Name
Address
City
State
Zip Code
Do you have any additional building and/or property owners to add?
1. Yes
1. No
Owner Name
Address
City
State
Zip Code
State the straight line distance from the property line of the following to the wall of the building where alcoholic beverages are sold.
Church
School
Library
Public Recreation
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Verification for License Application

Attach a passport-size photograph (front view) taken within the past two years. Write name on back of the photograph along with the name of the dealer submitting the license application.
Part IV
Verification
This pages cannot be completed online. It must be completed in ink.

State of Georgia
Greene County
I, ____________________________________________________________, do solemnly swear, subject to the penalties of false swearing, that the statements and answers made by me as the applicant in the foregoing Alcoholic Beverage Application are true.
_____________________________________________________________________
Applicant's Signature
I, ___________________________________________________________, hereby acknowledge that I have read and understand the Greene County Alcoholic Beverage Ordinance and that I have received copies of these Ordinances.
_____________________________________________________________________
Applicant's Signature
I, ____________________________________________________________, acknowledge that I am aware and understand that as a licensee I will be liable for any violations of either the Greene County Alcohol Ordinances or the laws of the state of Georgia, by myself, my employees, associates, partners or other person or entity affiliated with the licensed operation.
_____________________________________________________________________
Applicant's Signature

In making the above representation under oath, I understand that any person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a violation of O.C.G.A. § 16- 10-20, and face criminal penalties allowed by such statute.
Executed on the
__________ DAY OF ________________________________, 20_______.

in _________________________________ .

SUBSCRIBED AND SWORN BEFORE ME
ON THIS THE _________ DAY OF ________________________________, 20_______.

_____________________________________________________________________________
NOTARY PUBLIC

My Commission Expires: _________________________

AFFIX SEAL
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Alcoholic Beverage Personnel Statement

Instructions
- Type all information or write legibly in ink.
- Complete every question fully and correctly.
- If spaced provided is not sufficient, use separate sheet and indicate that answer is attached.
- Please use "N/A" for those questions that do not apply.
- When complete, application must be dated, signed and verified under oath by the licensee and filed with the County Clerk at 1034 Silver Drive, Suite 201, Greensboro, GA 30642 together will ALL supporting documents and applicable license fee(s) due.
Full Name of Applicant
Trade Name of Business of Which This Personnel Statement is a Part
Address of Business
City
State
Zip Code
Position of Applicant in Dealer's Business
State Ownership or Profit Sharing Interest
Salary
Annual Profit/Compensation Derived from this Business or Expected
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Personnel Statement - Financial Interests

Personnel Statement - Applicant Information

Do you have any other name that you have used in the past? If so, specify which and show dates.
1. Yes
1. No
Maiden name, names by former marriages, former names changed legally or other wide, aliases, nicknames, etc.
Name
Other Name Used
Changed By
marriage, alias, nickname, etc.
Date Used
Start Date thru End Date
Name
Other Name Used
Changed By
marriage, alias, nickname, etc.
Date Used
Start Date thru End Date
Name
Other Name Used
Changed By
marriage, alias, nickname, etc.
Date Used
Start Date thru End Date
Applicant's HOME Address
City
State
Zip Code
Applicant's BUSINESS Address
City
State
Zip Code
Due to the sensitive nature of the following questions, for the security of your private information, the form must be printed and completed by hand.
1. Applicant's Social Security Number: _____________________________
2. Applicant's Place of Birth: _________________________________
3. Applicants Date of Birth: ______________________________
4. US Citizen: Yes ________________ No ________________
5. If yes, choose one. By Birth __________________ Naturalized __________________
6. How many consecutive years and months have you been a legal resident of Georgia?: Years: __________________ Months: ___________________
7. Marital Status (Single, Married, Divorced, Widowed) ___________________________________
8. If married, divorced or widowed:
  1. Spouses Full name: _____________________________________
  2. Spouse's Place of Birth: _____________________________________
  3. Spouse's Date of Birth: _____________________________________
  4. Wife's Maiden Name: _____________________________________
9. Did you file a Georgia Income Tax Return for last calendar year? _________________________ If so, amount of taxes paid: ________________________________
10. Did you file and pay any county property tax for last calendar year? _______________________ If so, amount of taxes paid: ________________________ County: ___________________________
11. Did you file and pay any city property tax for last calendar year? __________________________ If so, amount of taxes paid: ________________________ City: ___________________________
12. Do you owe the State of Georgia any taxes or other charges? ___________________________ If so, explain: _________________________________________________________________________________________________________________________________________________________________________
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Personnel Statement Education / Employment

EDUCATION
Above Elementary , please provide the following:
Name of School
Address
Dates Attended
Degree / Certification
Do you have more schools to add?
1. Yes
1. No
Name of School
Address
Dates Attended
Degree / Certification
Do you have more schools to add?
1. Yes
1. No
Name of School
Address
Dates Attended
Degree / Certification
Employment Record
Most recent first., if self-employed, give details.
Name of Organization or Firm
Dates Employed
Dates Employed Start Date
—
Dates Employed End Date
State of Employment
Official Job Title
Salary
Start to End
Describe Specific Job Duties
Specific Reason for Leaving
Do you have more jobs to add?
1. Yes
1. No
Name of Organization or Firm
Dates Employed
Dates Employed Start Date
—
Dates Employed End Date
State of Employment
Official Job Title
Salary
Start to End
Describe Specific Job Duties
Specific Reason for Leaving
Do you have more jobs to add?
1. Yes
1. No
Name of Organization or Firm
Dates Employed
Dates Employed Start Date
—
Dates Employed End Date
State of Employment
Official Job Title
Salary
Start to End
Describe Specific Job Duties
Specific Reason for Leaving
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Personnel Statement - Residency / References

PLACES OF RESIDENCY
Most recent first.
Date Range
Date Range Start Date
—
Date Range End Date
Address
City
State
Zip Code
Do you have more places of residency to add?
1. Yes
1. No
Date Range
Date Range Start Date
—
Date Range End Date
Address
City
State
Zip Code
Do you have more places of residency to add?
1. Yes
1. No
Date Ramge
Date Ramge Start Date
—
Date Ramge End Date
Address
City
State
Zip Code
REFERENCES
Three personal references NOT relatives, former employers, fellow employees or school teachers who have now you well during the past five years.
Reference 1
Name
Number of Years Known
Residential Address
Business Address
Reference 2
Name
Number of Years Known
Residential Address
Business Address
Reference 3
Name
Number of Years Known
Residential Address
Business Address
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Personnel Statement - Military Service / Arrest Record

MILITARY SERVICE
Were you in any branch of the military?
1. Yes
1. No
Serial Number
Branch of Service
Period of Service
Period of Service Start Date
—
Period of Service End Date
Type of Discharge
ARREST RECORD
Have you ever been arrested or held by federal, state, or other law enforcement authorities, for any violation of any federal law, state law, county or municipal law, regulation or ordinances?
1. Yes
1. No
Do not include traffic violations.
Reason Charged or Held
Date
Date
Place Charged
Disposition
Do you have additional arrests to include?
1. Yes
1. No
Reason Charged or Held
Date
Date
Place Charged
Disposition
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Personnel Statement - Investment

INVESTMENT
State amount of capital that is, or will be, invested in business.
State amount of capital that you, the applicant, personally have invested, or will invest in business.
State amount of capital of business which is, or will be, borrowed.
Evidence of Indebtedness
Name of Lender
Address
Amount Borrowed
Date
Date
Interest Rate
Do you have additional lenders to add?
1. Yes
1. No
Name of Lender
Address
Amount Borrowed
Date
Date
Interest Rate
Include in your packet a copy of note(s) or other evidence of indebtedness with all amendments.
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Verification of Personnel Statement

Verification of Personnel Statement
I, ____________________________________________________________, do solemnly swear, subject to the penalties of false swearing, that the statements and answers made by me as the applicant in the foregoing Alcoholic Beverage Application are true.

_____________________________________________________________________
Applicant's Signature

In making the above representation under oath, I understand that any person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a violation of O.C.G.A. § 16- 10-20, and face criminal penalties allowed by such statute.
Executed on the
__________ DAY OF ________________________________, 20_______.

in _________________________________ .

SUBSCRIBED AND SWORN BEFORE ME
ON THIS THE _________ DAY OF ________________________________, 20_______.

_____________________________________________________________________________
NOTARY PUBLIC

My Commission Expires: _________________________

AFFIX SEAL
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Occupational Tax Certificate

Occupational Tax Certificate - Certifications / Business Information

CERTIFICATIONS
Does your business or occupation require State of Georgia licensure?
1. Yes
1. No
Provide license number.
A copy of your state license must be attached to the application packet.
BUSINESS INFORMATION
Date Business Started
Date Business Started
Company Type
Sole Proprietor, LLC, Corporation, etc.
Federal Employee Identification Number or Social Security Number if Sole Proprietor
Georgia Sales and Use Tax Number
If applicable
NAICS Code (Six Digit Number)
Look up your NAICS code by business type.
Number of Employees
E-Verify Number
Business Description
I certify that the information submitted is true and correct.

_______________________________________________________________________________
Signature of Applicant
_______________________________________________________________________________
Title
_______________________________________________________________________________
Date
OFFICE USE ONLY - PLEASE DO NOT FILL OUT
Reviewed by: _____________________________________________ Zoning: _____________________________________________
Permitted Use: ___________________ List Use: _____________________________________________
Other Reason for Allowing Occupancy Type: _____________________________________________
License #: _____________________________________________ Fee: ___________________ Payment: ___________________ Date: ___________________
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Private Employer Affidavit

PRIVATE EMPLOYER AFFIDAVIT
This form MUST be completed. If you select "Option A" you must list your Federal Work Program Authorization Number and the Date of Authorization. All forms must be signed by an authorized officer or agent of the business and notarized.
Private Employer Affidavit Pursuant to O.C.G.A. §36-60-6(d)
By executing this affidavit under oath, as an applicant for a Business License as referenced in O.C.G.A. §36 -60 -6(d), from Greene County, Georgia, the undersigned applicant representing the private employer known as
Name of Business
verifies one of the following with respect to the application for the above mentioned document:
Total Number of Employees
1. (Option A) 1 - 10 Employees
2. (Option B) 11 or More Employees
The employer has registered with and utilizes the federal work authorization program in accordance with the applicable provisions and deadlines established in O.C.G.A. §36-60-6. The undersigned private employer also attests that its federal work authorization user identification number (NOT YOUR FEDERAL TAX ID NUMBER) and date of authorization are as listed below:
Federal Work Authorization User Identification Number
Date of Authorization
ALL FORMS MUST BE SIGNED AND NOTARIZED.
In making the above representation under oath, I understand that any person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a violation of O.C.G.A. §16- 10-20, and face criminal penalties allowed by such statute.
Executed on the______ day of ___________________, 20____ in,___________________________________

___________________________________________________________________
Signature of Authorized Officer or Agent
___________________________________________________________________
Printed Name of and Title of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME ON THIS THE _______ DAY OF _______________________, 20________

___________________________________________________________________
Notary Public

___________________________________________________________________
My Commission Expires

AFFIX SEAL

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Alcoholic Beverage License Application with OTC and PEA

Steps

Checklist

License Requested

Business//Manager Information

Interested Parties

Building/Property Information

Verification for License Application

Verification

State of Georgia
Greene County

Alcoholic Beverage Personnel Statement

Personnel Statement - Financial Interests

Personnel Statement - Applicant Information

Personnel Statement Education / Employment

Personnel Statement - Residency / References

Personnel Statement - Military Service / Arrest Record

Personnel Statement - Investment

Verification of Personnel Statement

Occupational Tax Certificate

Occupational Tax Certificate - Certifications / Business Information

Private Employer Affidavit

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Alcoholic Beverage License Application with OTC and PEA

Steps

Checklist

License Requested

Business//Manager Information

Interested Parties

Building/Property Information

Verification for License Application

Verification

State of Georgia Greene County

Alcoholic Beverage Personnel Statement

Personnel Statement - Financial Interests

Personnel Statement - Applicant Information

Personnel Statement Education / Employment

Personnel Statement - Residency / References

Personnel Statement - Military Service / Arrest Record

Personnel Statement - Investment

Verification of Personnel Statement

Occupational Tax Certificate

Occupational Tax Certificate - Certifications / Business Information

Private Employer Affidavit

State of Georgia
Greene County