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NOTE: Once completed, this application must be printed and submitted in person along with your application fee(s).
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.
*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
Check all that apply.
BUSINESS REQUESTING LICENSE
If it is a Corporation/Partnership enter the Name and Address of Registered Agent.
If so, list the Name, Business Address, and Percent of Interest for each person, firm or corporation having any interest in this business.
Name(s) and Address(es) of Owner(s) of Building and Property
This pages cannot be completed online. It must be completed in ink.
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.
I, ___________________________________________________________, hereby acknowledge that I have read and understand the Greene County Alcoholic Beverage Ordinance and that I have received copies of these Ordinances.
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.
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_______.
My Commission Expires: _________________________
OTHER FINANCIAL INTERESTS
Maiden name, names by former marriages, former names changed legally or other wide, aliases, nicknames, etc.
Other Name Used
marriage, alias, nickname, etc.
Start Date thru End Date
Above Elementary , please provide the following:
Most recent first., if self-employed, give details.
Start to End
PLACES OF RESIDENCY
Most recent first.
Three personal references NOT relatives, former employers, fellow employees or school teachers who have now you well during the past five years.
Do not include traffic violations.
Evidence of Indebtedness
Include in your packet a copy of note(s) or other evidence of indebtedness with all amendments.
Greene CountyOccupational Tax Return1034 Silver Drive, Suite 201Greensboro, GA 30642
Phone (706) 453-7716
All applications must be filled out COMPLETELTY. In complete forms will NOT be processed.
(If different from owner. May include operator/manager, etc.)
A copy of your state license must be attached to the application packet.
Sole Proprietor, LLC, Corporation, etc.
Look up your NAICS code by business type.
I certify that the information submitted is true and correct.
_______________________________________________________________________________Signature of Applicant
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: ___________________
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
verifies one of the following with respect to the application for the above mentioned document:
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:
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________
___________________________________________________________________My Commission Expires
* indicates a required field