Exhibit 7- COG New Liquor Application Packet.pdf

DR 8404 (07/07/23)

COLORADO DEPARTMENT OF REVENUE

Liquor Enforcement Division

(303) 205-2300

Colorado Liquor Retail License Application

* Note that the Division will not accept cash Paid by check Paid online Uploaded to MoveIt on

Date

New License New-Concurrent Transfer of Ownership State Property Only Master file

• All answers must be printed in black ink or typewritten

• Applicant must check the appropriate box(es)

• Applicant should obtain a copy of the Colorado Liquor, Beer and Wine Code: SBG.Colorado.gov/Liquor

1. Applicant is applying as a/an Individual Limited Liability Company Association or Other Corporation Partnership (includes Limited Liability and Husband and Wife Partnerships)

2. Applicant If an LLC, name of LLC; if partnership, at least 2 partner's names; if corporation, name of corporation FEIN Number

2a. Trade Name of Establishment (DBA) State Sales Tax Number Business Telephone

3. Address of Premises (specify exact location of premises, include suite/unit numbers)

City County State ZIP Code

4. Mailing Address (Number and Street) City or Town State ZIP Code

5. Email Address

6. If the premises currently has a liquor or beer license, you must answer the following questions Present Trade Name of Establishment (DBA) Present State License Number Present Class of License Present Expiration Date

Section A Nonrefundable Application Fees* Section B (Cont.) Liquor License Fees*

Application Fee for New License ............................................$1,100.00 Application Fee for New License w/Concurrent Review ............$1,200.00 Application Fee for Transfer ...................................................$1,100.00

Liquor–Licensed Drugstore (County) ..................................................$312.50 Lodging & Entertainment - L&E (City) .................................................$500.00 Lodging & Entertainment - L&E (County) ...........................................$500.00 Manager Registration - H & R ................................................................$30.00 Manager Registration - Tavern ...............................................................$30.00 Manager Registration - Lodging & Entertainment ................................$30.00 Manager Registration - Campus Liquor Complex ...............................$30.00 Optional Premises License (City) .........................................................$500.00 Optional Premises License (County) ...................................................$500.00 Racetrack License (City) .......................................................................$500.00 Racetrack License (County) .................................................................$500.00 Resort Complex License (City).............................................................$500.00 Resort Complex License (County) .......................................................$500.00 Related Facility - Campus Liquor Complex (City) .............................. $160.00 Related Facility - Campus Liquor Complex (County) ........................ $160.00 Related Facility - Campus Liquor Complex (State) ............................ $160.00 Retail Gaming Tavern License (City) ...................................................$500.00 Retail Gaming Tavern License (County) ..............................................$500.00 Retail Liquor Store License--Additional (City) ......................................$227.50 Retail Liquor Store License--Additional (County) ................................$312.50 Retail Liquor Store (City) .......................................................................$227.50 Retail Liquor Store (County) .................................................................$312.50 Tavern License (City) ..........................................................................$500.00 Tavern License (County) ....................................................................$500.00 Vintners Restaurant License (City) ......................................................$750.00 Vintners Restaurant License (County) .................................................$750.00

Section B Liquor License Fees*

Add Optional Premises to H & R .........$100.00 X ________ Total ________

Add Related Facility to Resort Complex $75.00 X ________ Total ________ Add Sidewalk Service Area.................................................................... $75.00 Arts License (City) ................................................................................ $308.75 Arts License (County) .......................................................................... $308.75 Beer and Wine License (City) .............................................................. $351.25 Beer and Wine License (County) ........................................................ $436.25 Brew Pub License (City) .................................................................... $750.00 Brew Pub License (County) ................................................................. $750.00 Campus Liquor Complex (City) ........................................................... $500.00 Campus Liquor Complex (County) ..................................................... $500.00 Campus Liquor Complex (State) ......................................................... $500.00 Club License (City) ............................................................................... $308.75 Club License (County) ........................................................................ $308.75 Distillery Pub License (City) ................................................................. $750.00 Distillery Pub License (County) ........................................................... $750.00 Hotel and Restaurant License (City) ................................................... $500.00 Hotel and Restaurant License (County) ............................................ $500.00 Hotel and Restaurant License w/one opt premises (City) ................. $600.00 Hotel and Restaurant License w/one opt premises (County) ............ $600.00 Liquor–Licensed Drugstore (City) ....................................................... $227.50

Questions? Visit: SBG.Colorado.gov/Liquor for more information Do not write in this space - For Department of Revenue use only

Liability Information License Account Number Liability Date License Issued Through (Expiration Date) Total

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SBG.colorado.gov/liquor SBG.colorado.gov/liquor

DR 8404 (07/07/23) Page 2 of 6

Application Documents Checklist and Worksheet Instructions: This checklist 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. Questions? Visit: SBG.Colorado.gov/Liquor for more information

Items submitted, please check all appropriate boxes completed or documents submitted I. Applicant information

A. Applicant/Licensee identified B. State sales tax license number listed or applied for at time of application C. License type or other transaction identified D. Return originals to local authority (additional items may be required by the local licensing authority) E. All sections of the application need to be completed F. Master file applicants must include the Application for Master File form DR 8415 and applicable fees to this

Retail License Application II. Diagram of the premises

A. No larger than 8½" X 11" B. Dimensions included (does not have to be to scale). Exterior areas should show type of control (fences, walls, entry/exit points, etc.)

C. Separate diagram for each floor (if multiple levels) D. Kitchen - identified if Hotel and Restaurant, include bar, tables, bathrooms E. RED Bold/Outlined Licensed Premises, include name and address of establishment, with directional arrow

III. Proof of property possession (One Year Needed) A. Deed in name of the applicant (or) (matching question #2) date stamped / filed with County Clerk B. Lease in the name of the applicant (or) (matching question #2) C. Lease assignment in the name of the applicant with proper consent from the landlord and acceptance by the applicant D. Other agreement if not deed or lease. (matching question #2)

IV. Background information (DR 8404-I) and financial documents A. Complete DR 8404-I for each principal (individuals with more than 10% ownership, officers, directors, partners, members) B. Fingerprints taken & submitted to the appropriate Local Licensing Authority through an approved State Vendor.

Master File applicants submit results to the State using code 25YQHT with IdentoGO.

Do not complete fingerprint cards prior to submitting your application.

The Vendors are as follows:

IdentoGO – https://uenroll.identogo.com/ Phone: 844-539-5539 Service Code 25YQ6K & CBI Account # CONCJ6253 Colorado Fingerprinting – http://www.colorado ingerprinting.com Appointment Scheduling Website: http://www.colorado ingerprinting.com/cabs/ Phone: 720-292-2722 Service Code: 6253LLQH & CBI Account # CONCJ6253

C. Purchase agreement, stock transfer agreement, and/or authorization to transfer license D. List of all notes and loans (Copies to also be attached)

V. Sole proprietor/husband and wife partnership (if applicable) A. Form DR 4679 B. Copy of State issued Driver’s License or Colorado Identification Card for each applicant

VI. Corporate applicant information (if applicable) A. Certificate of Incorporation B. Certificate of Good Standing C. Certificate of Authorization if foreign corporation (out of state applicants only)

VII. Partnership applicant information (if applicable) A. Partnership Agreement (general or limited).

B. Certificate of Good Standing

VIII. Limited Liability Company applicant information (if applicable) A. Copy of articles of organization B. Certificate of Good Standing C. Copy of Operating Agreement (if applicable) D. Certificate of Authority if foreign LLC (out of state applicants only)

IX. Manager registration for Hotel and Restaurant, Tavern, Lodging & Entertainment, and Campus Liquor Complex licenses when included with this application

A. $30.00 fee B. If owner is managing, no fee required

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DR 8404 (07/07/23) Page 3 of 6

Name (matching question #2) Type of License Account Number

7. Is the applicant (including any of the partners if a partnership; members or managers if a limited liability company;

or officers, stockholders or directors if a corporation) or managers under the age of twenty-one years?

Yes No

8. Has the applicant (including any of the partners if a partnership; members or managers if a limited liability company; or officers, stockholders or directors if a corporation) or managers ever (in Colorado or any other state):

a. Been denied an alcohol beverage license?

b. Had an alcohol beverage license suspended or revoked?

c. Had interest in another entity that had an alcohol beverage license suspended or revoked?

If you answered yes to 8a, b or c, explain in detail on a separate sheet.

9. 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.

10. 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?

Waiver by local ordinance?

Other: ________________ or

11. Is your Liquor Licensed Drugstore (LLDS) or Retail Liquor Store (RLS) within 1500 feet of another retail liquor license for off-premises sales in a jurisdiction with a population of greater than (>) 10,0000? NOTE: The distance shall be determined by a radius measurement that begins at the principal doorway of the LLDS/RLS premises for which the application is being made and ends at the principal doorway of the Licensed LLDS/RLS.

12. Is your Liquor Licensed Drugstore (LLDS) or Retail Liquor Store (RLS) within 3000 feet of another retail liquor license for off-premises sales in a jurisdiction with a population of less than (<) 10,0000? NOTE: The distance shall be determined by a radius measurement that begins at the principal doorway of the LLDS/RLS premises for which the application is being made and ends at the principal doorway of the Licensed LLDS/RLS.

13. a. For additional Retail Liquor Store only. Was your Retail Liquor Store License issued on or before January 1, 2016?

b. Are you a Colorado resident?

14. 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 financial interest in said business including any loans to or from a licensee.

15. Does the applicant, as listed on line 2 of this application, have legal possession of the premises by ownership, lease or other arrangement?

Ownership Lease Other (Explain in Detail) _______________________________________________

a. If leased, list name of landlord and tenant, and date of expiration, exactly as they appear on the lease:

Landlord Tenant Expires

b. Is a percentage of alcohol sales included as compensation to the landlord? If yes, complete question 16.

c. Attach a diagram that designates the area to be licensed in black bold outline (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 8½" X 11".

16. 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.

Last Name First Name Date of Birth FEIN or SSN Interest/Percentage

Last Name First Name Date of Birth FEIN or SSN Interest/Percentage

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.

17. Optional Premises or Hotel and Restaurant Licenses with Optional Premises:

Has a local ordinance or resolution authorizing optional premises been adopted?

Number of additional Optional Premise areas requested. (See license fee chart)

18. For the addition of a Sidewalk Service Area per Regulation 47-302(A)(4), include a diagram of the service area and documentation received from the local governing body authorizing use of the sidewalk. Documentation may include but is not limited to a statement of use, permit, easement, or other legal permissions.

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DR 8404 (07/07/23) Page 4 of 6

19. Liquor Licensed Drugstore (LLDS) applicants, answer the following:

a. Is there a pharmacy, licensed by the Colorado Board of Pharmacy, located within the applicant's LLDS premise?

If "yes" a copy of license must be attached.

20. Club Liquor License applicants answer the following: Attach a copy of applicable documentation Yes No

a. Is the applicant organization operated solely for a national, social, fraternal, patriotic, political or athletic purpose and not for pecuniary gain?

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?

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?

21. Brew-Pub, Distillery Pub or Vintner's Restaurant applicants answer the following:

a. Has the applicant received or applied for a Federal Permit? (Copy of permit or application must be attached)

22. Campus Liquor Complex applicants answer the following:

a. Is the applicant an institution of higher education?

b. Is the applicant a person who contracts with the institution of higher education to provide food services?

If "yes" please provide a copy of the contract with the institution of higher education to provide food services.

23. For all on-premises applicants.

a. For all Liquor Licensed Drugstores (LLDS) the Permitted Manager must also submit an Manager Permit Application

- DR 8000 and fingerprints.

Last Name of Manager First Name of Manager

24. Does this manager act as the manager of, or have a financial interest in, any other liquor licensed establishment in the State of Colorado? If yes, provide name, type of license and account number.

Yes No

25. Related Facility - Campus Liquor Complex applicants answer the following:

a. Is the related facility located within the boundaries of the Campus Liquor Complex?

If yes, please provide a map of the geographical location within the Campus Liquor Complex.

If no, this license type is not available for issues outside the geographical location of the Campus Liquor Complex.

b. Designated Manager for Related Facility- Campus Liquor Complex Last Name of Manager First Name of Manager

26. Tax Information.

a. Has the applicant, including its manager, partners, officer, directors, stockholders, members (LLC), managing members (LLC), or any other person with a 10% or greater financial interest in the applicant, been found in final order of a tax agency to be delinquent in the payment of any state or local taxes, penalties, or interest related to a business?

b. Has the applicant, including its manager, partners, officer, directors, stockholders, members (LLC), managing members (LLC), or any other person with a 10% or greater financial interest in the applicant failed to pay any fees or surcharges imposed pursuant to section 44-3-503, C.R.S.?

Yes No

27. 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 ownership of 10% or more in the applicant. All persons listed below must also attach form DR 8404-I (Individual History Record), and make an appointment with an approved State Vendor through their website. See application checklist, Section IV, for details.

Name Home Address, City & State DOB Position %Owned

Name Home Address, City & State DOB Position %Owned

Name Home Address, City & State DOB Position %Owned

Name Home Address, City & State DOB Position %Owned

Name Home Address, City & State DOB Position %Owned

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DR 8404 (07/07/23) Page 5 of 6

** If applicant is owned 100% by a parent company, please list the designated principal officer on above.

** Corporations - the President, Vice-President, Secretary and Treasurer must be accounted for above (Include ownership percentage if applicable) ** If total ownership percentage disclosed here does not total 100%, applicant must check this box:

Applicant affirms that no individual other than these disclosed herein owns 10% or more of the applicant and does not have financial interest in a prohibited liquor license pursuant to Article 3 or 5, C.R.S.

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 Printed Name and Title Date

Report and Approval of Local Licensing Authority (City/County) Date application filed with local authority Date of local authority hearing (for new license applicants; cannot be less than 30 days from date of application)

For Transfer Applications Only - Is the license being transferred valid?

Yes No

The Local Licensing Authority Hereby Affirms that each person required to file DR 8404-I (Individual History Record) or a DR 8000 (Manager Permit) has been:

Fingerprinted Subject to background investigation, including NCIC/CCIC check for outstanding warrants

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 affecting their class of license (Check One)

Date of inspection or anticipated date _____________________ Will conduct inspection upon approval of state licensing authority

Is the Liquor Licensed Drugstore (LLDS) or Retail Liquor Store (RLS) within 1,500 feet of another retail liquor license for off-premises sales in a jurisdiction with a population of > 10,0000?

Yes No

Is the Liquor Licensed Drugstore(LLDS) or Retail Liquor Store (RLS) within 3,000 feet of another retail liquor license for off-premises sales in a jurisdiction with a population of < 10,0000?

NOTE: The distance shall be determined by a radius measurement that begins at the principal doorway of the LLDS/RLS premises for which the application is being made and ends at the principal doorway of the Licensed LLDS/RLS.

Does the Liquor-Licensed Drugstore (LLDS) have at least twenty percent (20%) of the applicant's gross annual income derived from the sale of food, during the prior twelve (12) month period?

The foregoing application has been examined; and the premises, business to be conducted, and character of the appli-cant are satisfactory. We do report that such license, if granted, will meet the reasonable requirements of the neighbor-hood and the desires of the adult inhabitants, and will comply with the provisions of Title 44, Article 4 or 3, C.R.S., and Liquor Rules. Therefore, this application is approved.

Local Licensing Authority for Telephone Number Town, City

County Signature Print Title Date

Signature Print Title Date

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Tax Check Authorization, Waiver, and Request to Release Information

I, am signing this Tax Check Authorization, Waiver and Request to Release Information (hereinafter “Waiver”) on behalf of (the “Applicant/Licensee”) to permit the Colorado Department of Revenue and any other state or local taxing authority to release information and documentation that may otherwise be confidential, as provided below. If I am signing this Waiver for someone other than myself, including on behalf of a business entity, I certify that I have the authority to execute this Waiver on behalf of the Applicant/Licensee.

The Executive Director of the Colorado Department of Revenue is the State Licensing Authority, and oversees the Colorado Liquor Enforcement Division as his or her agents, clerks, and employees. The information and documentation obtained pursuant to this Waiver may be used in connection with the Applicant/Licensee’s liquor license application and ongoing licensure by the state and local licensing authorities. The Colorado Liquor Code, section 44-3-101. et seq.

(“Liquor Code”), and the Colorado Liquor Rules, 1 CCR 203-2 (“Liquor Rules”), require compliance with certain tax obligations, and set forth the investigative, disciplinary and licensure actions the state and local licensing authorities may take for violations of the Liquor Code and Liquor Rules, including failure to meet tax reporting and payment obligations.

The Waiver is made pursuant to section 39-21-113(4), C.R.S., and any other law, regulation, resolution or ordinance concerning the confidentiality of tax information, or any document, report or return filed in connection with state or local taxes. This Waiver shall be valid until the expiration or revocation of a license, or until both the state and local licensing authorities take final action to approve or deny any application(s) for the renewal of the license, whichever is later.

Applicant/Licensee agrees to execute a new waiver for each subsequent licensing period in connection with the renewal of any license, if requested.

By signing below, Applicant/Licensee requests that the Colorado Department of Revenue and any other state or local taxing authority or agency in the possession of tax documents or information, release information and documentation to the Colorado Liquor Enforcement Division, and is duly authorized employees, to act as the Applicant’s/Licensee’s duly authorized representative under section 39-21-113(4), C.R.S., solely to allow the state and local licensing authorities, and their duly authorized employees, to investigate compliance with the Liquor Code and Liquor Rules. Applicant/Licensee authorizes the state and local licensing authorities, their duly authorized employees, and their legal representatives, to use the information and documentation obtained using this Waiver in any administrative or judicial action regarding the application or license.

Name (Individual/Business) Social Security Number/Tax Identification Number

Address

City State Zip

Home Phone Number Business/Work Phone Number

Printed name of person signing on behalf of the Applicant/Licensee

Applicant/Licensee’s Signature (Signature authorizing the disclosure of confidential tax information) Date signed

Privacy Act Statement Providing your Social Security Number is voluntary and no right, benefit or privilege provided by law will be denied as a result of refusal to disclose it. § 7 of Privacy Act, 5 USCS § 552a (note).

DR 8495 (07/23/19)

COLORADO DEPARTMENT OF REVENUE

Liquor Enforcement Division

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City of Greeley Attachment to New Liquor/ Beer Retail Liquor License or Renewal Application

(Please type or print legibly)

Completion of the following information will aid in the review of your application for a new liquor or beer license or annual License Renewal Application in the City Clerk’s Office, as well as review of a possible application to operate an Entertainment Establishment you may have submitted to the Community Development Department. Please answer in detail.

1. Describe the nature of the proposed establishment and the target market (restaurant, tavern, sports bar, families, college students, etc.):

2. What are the proposed hours and days of operation for the establishment?

3. How many individuals will be employed at this proposed establishment and how many will be full-time versus part-time? (Please provide responsibilities, for example, assistant manager, bartender, waitstaff, doorstaff, etc.)

4. What is the ratio of staff to patrons for both average and peak hours of operation?

5. Describe your past training and experience in the sale/service of alcohol beverages (include any special or certified training received):

6. Describe your proposed operating manager’s past training and experience in the sale/service of alcohol beverages (include any special or certified training received):

7. What type of training is proposed for employees at this establishment in the safe and legal sale/service of alcohol beverages?

8. Describe any other types of training or operating procedures that employees will be following in the day-to-day operation of this proposed establishment:

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9. What methods will be used in checking identification for proper age of patrons (at the door, at the bar, etc.) and how will underage patrons be identified so as not to be served alcohol beverages (stamp, wrist band, etc.)?

10. Describe how the business will manage patron and employee conformance with no smoking laws, noise, and other nuisance behaviors (trash, intimidation of other parties, etc.) while on the premises:

11. What types of entertainment will be offered, if any, at this proposed establishment? (for example, music, pool, darts, etc.):

12. Describe special promotions or activities that may attract a larger than typical attendance and any additional or special management practices that will be employed to handle such increased attendance:

13. What types of security, if any will be provided at this proposed establishment, and will they be armed in any way?

14. If security is planned, who will provide such service, and have all applicable licenses been obtained?

15. What is the building’s occupancy limit? _________ Describe an emergency building exit plan?

16. What types of alternate beverages and food/snacks will be provided at this proposed establishment?

17. What is the estimated ratio of food sales to alcohol beverage sales at this establishment?

I hereby certify, under penalty of perjury, that the information provided to the Greeley Liquor Licensing Authority contained in this Attachment to Liquor/Beer Retail License Application is true and accurate to the best of my knowledge.

Applicant’s Signature Date

Name of Business:_______________________________

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DR 8404-I (03/20/19)

COLORADO DEPARTMENT OF REVENUE

Liquor Enforcement Division

(303) 205-2300

Individual History Record To be completed by the following persons, as applicable: sole proprietors; general partners regardless of percentage ownership, and limited partners owning 10% or more of the partnership; all principal officers of a corporation, all directors of a corporation, and any stockholder of a corporation owning 10% or more of the outstanding stock; managing members or officers of a limited liability company, and members owning 10% or more of the company; and any intended registered manager of Hotel and Restaurant, Tavern and Lodging and Entertainment class of retail license

Notice: This individual history record requires information that is necessary for the licensing investigation or inquiry. All questions must be answered in their entirety or the license application may be delayed or denied. If a question is not applicable, please indicate so by “N/A”. Any deliberate misrepresentation or material omission may jeopardize the license application. (Please attach a separate sheet if necessary to enable you to answer questions completely)

1. Name of Business Home Phone Number Cellular Number

2. Your Full Name (last, first, middle) 3. List any other names you have used

4. Mailing address (if different from residence) Email Address

5. List current residence address. Include any previous addresses within the last five years. (Attach separate sheet if necessary) Street and Number City, State, Zip From To

Current

Previous

6. List all employment within the last five years. Include any self-employment. (Attach separate sheet if necessary) Name of Employer or Business Address (Street, Number, City, State, Zip) Position Held From To

7. List the name(s) of relatives working in or holding a financial interest in the Colorado alcohol beverage industry.

Name of Relative Relationship to You Position Held Name of Licensee

8. Have you ever applied for, held, or had an interest in a Colorado Liquor or Beer License, or loaned money, furniture, fixtures, equipment or inventory to any licensee? (If yes, answer in detail.) Yes No

9. Have you ever received a violation notice, suspension, or revocation for a liquor law violation, or have you applied for or been denied a liquor or beer license anywhere in the United States? (If yes, explain in detail.) Yes No

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10. Have you ever been convicted of a crime or received a suspended sentence, deferred sentence, or forfeited bail for any offense in criminal or military court or do you have any charges pending? (If yes, explain in detail.) Yes No

11. Are you currently under probation (supervised or unsupervised), parole, or completing the requirements of a deferred sentence? (If yes, explain in detail.) Yes No

12. Have you ever had any professional license suspended, revoked, or denied? (If yes, explain in detail.) Yes No Personal and Financial Information

Unless otherwise provided by law, the personal information required in question #13 will be treated as confidential. The personal information required in question #13 is solely for identification purposes.

13a. Date of Birth b. Social Security Number c. Place of Birth

d. U.S. Citizen Yes No

e. If Naturalized, state where f. When g. Name of District Court

h. Naturalization Certificate Number i. Date of Certification j. If an Alien, Give Alien’s Registration Card Number k. Permanent Residence Card Number

l. Height m. Weight n. Hair Color o. Eye Color p. Gender q. Do you have a current Driver’s License/ID? If so, give number and state.

Yes No # __________________ State _________________

14. Financial Information.

a. Total purchase price or investment being made by the applying entity, corporation, partnership, limited liability company, other.

b. List the total amount of the personal investment , made by the person listed on question #2, in this business including any notes, loans, cash, services or equipment, operating capital, stock purchases or fees paid. $ __________________________

* If corporate investment only please skip to and complete section (d) ** Section b should reflect the total of sections c and e

c. Provide details of the personal investment described in 14b. You must account for all of the sources of this investment.

(Attach a separate sheet if needed)

Type: Cash, Services or Equipment Account Type Bank Name Amount

d. Provide details of the corporate investment described in 14 (a). You must account for all of the sources of this investment. (Attach a separate sheet if needed)

Type: Cash, Services or Equipment Loans Account Type Bank Name Amount

e. Loan Information (Attach copies of all notes or loans) Name of Lender Address Term Security Amount

Oath of Applicant I declare under penalty of perjury that this application and all attachments are true, correct, and complete to the best of my knowledge.

Authorized Signature Print Signature Title Date

DR 8404-I (03/20/19)

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Authorization and Consent to Release Information

Applicant – Complete Below and Sign Name of Individual (Please Print:

Title:

Trade Name of Establishment (DBA):

Address of Establishment:

I, as an applicant for the above references liquor license, with the City of Greeley, am required to be fingerprinted and to undergo a criminal record review. I do hereby consent to be fingerprinted and to said criminal record review, and further agree to the following terms and conditions:

1. The fingerprints will be used to check the criminal history records of the Federal Bureau of Investigation (FBI) and the Colorado Bureau of Investigation (CBI).

2. I hereby authorize the FBI and the CBI to release criminal history information to the City of Greeley.

3. I understand that all information provided to the City of Greely will be held in a confidential manner by the City Clerk’s Office for the City of Greely.

4. I herby release you, your organization, or others from any liability or damage which may result from furnishing the information requested, I further authorize the City of Greeley and the Local Licensing Authority to discuss, in a public forum, any and all findings in regard to my moral, educational, and character qualifications should I wish to process to that stage of the process of application. I understand that any information or records obtained from you or by the City may become public records available upon request by the public.

Signature Date

STATE OF COLORADO ) ) SS. COUNTY OF WELD ) Subscribed and sworn to before me this ______ day of ________________________, 2022. Witness my hand and official seal, Notary Public My commission expires ______________________

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NONCRIMINAL JUSTICE APPLICANT’S PRIVACY RIGHTS

As an applicant who is the subject of a national fingerprint-based criminal history record check for a noncriminal justice purpose (such as an application for employment or a license, an immigration or naturalization matter, security clearance, or adoption), you have certain rights which are discussed below.

You must be provided written notification1 that your fingerprints will be used to check the criminal history records of the FBI.

You must be provided, and acknowledge receipt of, an adequate Privacy Act Statement when you submit your fingerprints and associated personal information. This Privacy Act

Statement should explain the authority for collecting your information and how your information will be used, retained, and shared. 2

If you have a criminal history record, the officials making a determination of your suitability for the employment, license, or other benefit must provide you the opportunity to complete or challenge the accuracy of the information in the record.

The officials must advise you that the procedures for obtaining a change, correction, or update of your criminal history record are set forth at Title 28, Code of Federal Regulations

(CFR), Section 16.34.

If you have a criminal history record, you should be afforded a reasonable amount of time to correct or complete the record (or decline to do so) before the officials deny you the employment, license, or other benefit based on information in the criminal history record.3

You have the right to expect that officials receiving the results of the criminal history record check will use it only for authorized purposes and will not retain or disseminate it in violation of federal statute, regulation or executive order, or rule, procedure or standard established by the

National Crime Prevention and Privacy Compact Council.4

If agency policy permits, the officials may provide you with a copy of your FBI criminal history record for review and possible challenge. If agency policy does not permit it to provide you a copy of the record, you may obtain a copy of the record by submitting fingerprints and a fee to the FBI. Information regarding this process may be obtained at https://www.fbi.gov/services/cjis/identity-history-summary-checks.

If you decide to challenge the accuracy or completeness of your FBI criminal history record, you should send your challenge to the agency that contributed the questioned information to the

FBI. Alternatively, you may send your challenge directly to the FBI. The FBI will then forward your challenge to the agency that contributed the questioned information and request the agency to verify or correct the challenged entry. Upon receipt of an official communication from that agency, the FBI will make any necessary changes/corrections to your record in accordance with the information supplied by that agency. (See 28 CFR 16.30 through 16.34.)

1 Written notification includes electronic notification, but excludes oral notification.

2 https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement 3 See 28 CFR 50.12(b).

4 See 5 U.S.C. 552a(b); 28 U.S.C. 534(b); 34 U.S.C. § 40316 (formerly cited as 42 U.S.C. § 14616), Article IV(c);

28 CFR 20.21(c), 20.33(d) and 906.2(d).

Updated 05/10/2017

Non-substantive updates incorporated in January 2018

Exa mple fill https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement https://www.fbi.gov/services/cjis/identity-history-summary-checks

All documents must be properly signed and correspond with the name of the applicant exactly