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Home My WebLink AboutChange_of_Agent_Application_PacketAlcohol Beverage Appointment of Agent Form AB-101 Date Part A: Business Information 1. Legal Business Name (individual name if sole proprietor) 3. Entity Type (check one) 2. Business Trade Name or DBA 6. Describe the reason for appointing a successor agent, if successor is checked above. 4. Alcohol Beverage Business Authorization (check one)5. If successor agent, provide State Permit or Municipal Retail License Number Municipal Retail License State Permit Limited Liability Company Corporation Nonprofit Organization AB-101 (N. 03-24)Wisconsin Department of Revenue- 1 - Continued → Agent Type (check one) Original (no fee)Successor ($10 fee for municipal licensees only) Part C: Agent Questions 1. Have you satisfied the responsible beverage server training requirement? . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No Submit proof of completion. 2. Have you completed Form AB-100, Alcohol Beverage Individual Questionnaire?. . . . . . . . . . . . . . . . . . . . . . . . Yes No Submit a completed Form AB-100 with this form. 3. Have you been a Wisconsin resident for at least 90 continuous days?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No See instructions for exceptions. Part B: Agent Information 4. Email 6. Home Address 5. Phone 7. City 11. Drivers License/State ID Number 12. Drivers License/State ID State of Issuance 8. State 10. Age9. Zip Code 1. Last Name 2. First Name 3. M.I. Part D: Business Attestation READ CAREFULLY BEFORE SIGNING: I, the Undersigned, authorize the above-named individual to act for the above-named corporation, nonprofit organization, or limited liability company with full authority and control of the premises and of all alcohol beverage activities on such premises. I certify that I am authorized by the above-named entity to authorize this individual to act on behalf of the entity. If I am appointing a successor agent, I rescind all previous agent appointments for this premises. Further, I understand that I may be prosecuted for submitting false statements and affidavits in connection with this application, and that any person who knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. AB-101 (N. 03-24)- 2 - Signature Date Last Name First Name M.I. Title Email Phone READ CAREFULLY BEFORE SIGNING: I, the Agent, hereby accept this appointment as agent for the above-named corporation, nonprofit organization, or limited liability company and assume full responsibility for the conduct of all alcohol beverage activities on the premises for the above-named business. I further understand that I may be prosecuted for submitting false statements and affidavits in connection with this application, and that any person who knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Part E: Agent Attestation Signature Date Last Name First Name M.I. Who must complete Form AB-101? State law requires corporations and limited liability companies (LLCs) to appoint an agent that takes responsibility for the licensed or permitted premises. Use this form to appoint an agent for a new premises or to appoint a successor agent when there is a change before the license or permit is up for renewal. Where do I submit Form AB-101? Submit Form AB-101 to the appropriate issuing authority, either the clerk of the municipality in which the business or organization is located, or the Division of Alcohol Beverages. Form AB-101 may be submitted with a license or permit application or at any time to indicate there is a change in agent prior to the license or permit renewal period. Specific Instructions Date: • Date the form in the top right corner. Agent Type: • Select original appointment if you are applying for your license or permit for the first time or are renewing a license or permit. • Select successor agent if you are reporting a change of agent during the licensing or permitting period. Part A: Business Information • Box 1: Enter the legal business name. If a sole-proprietorship, enter the individual’s first and last name. • Box 2: Enter the trade name or “doing business as”, if different than the name in box 1. • Box 3: Check one entity type to indicate how the business is legally organized. Note: This business information must match the information on the license or permit application. • Box 4: Select which alcohol beverage authorization you hold or are applying for. • Box 5: For appointment of a successor agent, enter your state permit number (15-digit Wisconsin Tax ID number) or municipal retail license number (if applicable) for which you are appointing a successor agent. If you do not have a municipal retail license number, provide any applicable identifier (e.g., store number or location). • Box 6: For appointment of a successor agent, describe the reason for the change in agent. Part B: Agent Information • Provide all requested personal information. Part C: Agent Questions • Question 1: Wisconsin law requires all agents of corporations and LLCs to successfully complete a Wisconsin approved responsible beverage server (RBS) training course within the past two years unless: ◦The applicant is renewing a municipal alcohol beverage retail license, or ◦Within the past two years: a. The applicant held a manager’s or operator’s (bartender) license. b. The applicant held or was the agent of a corporation or LLC that held any municipally issued retail alcohol beverage license in Wisconsin. Form AB-101 Instructions Alcohol Beverage Appointment of Agent Form AB-101 Instructions - 1 -Wisconsin Department of Revenue • Some agents for state permittees are exempt from responsible beverage server course requirements. The following permittees are exempt from RBS course requirements: Alcohol Beverage Warehouse, Industrial Fermented Malt Beverages, Wholesalers, Manufacturers, Rectifiers, Direct Wine Shippers, Wholesale Alcohol, Medicinal Alcohol, Industrial Alcohol, and Industrial Wine. ◦If you are applying to be the agent of one of these exempt permittees, answer “yes” to Question 1. • To learn about your responsibility to complete the responsible beverage server requirement, review Publication 302, Information for Wisconsin Alcohol Beverage and Tobacco Retailers. • Question 2: Appointed agents must submit Form AB-100, Alcohol Beverage Individual Questionnaire, in addition to this form. • Question 3: Appointed agents must be Wisconsin residents for at least 90 continuous days prior to the date of application, except for direct wine shipper permittees. Part D: Business Attestation • An authorized representative should sign, date, and provide requested personal information on behalf of the business. Part E: Agent Attestation • The agent being appointed should read the attestation carefully, then sign and date. Assistance If you have questions about alcohol beverage laws and regulations, you may contact the Department of Revenue using the contact information below. Website: DOR Alcohol Beverage (wi.gov) Write: DORAlcohol@wisconsin.gov Call: (608) 264-4573 - 2 -Form AB-101 Instructions Oshkosh Police Department Investigation for City Liquor License APPLICANT INFORMATION Last Name First M.I. Date Street Address Apartment/Unit # City State ZIP Phone E-mail Place of Birth Date of Birth Previous Name Previous Address (up to the last 5 years) BUSINESS WHERE LIQUOR LICENSE WILL BE HELD Name Phone Address License Type What type of establishment do you intend to operate? ____Retail ____Restaurant ____Tavern / Bar ____Nightclub Do you understand the State Statues & City Ordinances concerning the laws & regulations in the operation of this establishment? YES NO Do you understand there must be a licensed bartender or yourself on duty at all times. YES NO Will you have any type of entertainment? If so, what type? YES NO Will your music be kept at a level acceptable to the neighborhood? YES NO Do you understand that the license you are applying for will expire June 30th of each year and that checks will be made by the Police Department, that records will be kept of complaints and these records may have a bearing on the Common Council renewing any future licenses? YES NO What experience do you have in the operation of this type of establishment? How will you prevent underage drinking on premises? Have you ever been convicted of violating any federal, state, local laws or ordinances related to alcohol beverages - If yes, please explain: YES NO Signature of Applicant Date Applicant Approved YES NO Signature of Investigating Officer Date Council Date