Apply for Alcoholic Beverage License: Intake Form Please submit the following information via this online form, which is encrypted with SSL to help ensure the data you enter is secure. Name* Prefix Mr.Ms.Other First Middle Last Suffix Email* Enter Email Confirm Email Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Business InformationBusiness Name*Please include the full legal business name including punctuation and the entity suffix (LLC, Inc., etc.)Business DBA ("Assumed Name")The name the business goes by other than its legal name, if applicable.Business Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Business Phone Number*Business Fax NumberBusiness Email Address Business Website Business EIN*Federal tax ID number.First Owner InformationNote: Sometimes the person completing this form is not one of the business owners. If that is the case, please enter information about the first owner below and keep your contact information above. If one of the owners IS submitting this form, please re-enter below your name, email, phone, and address fields which you also entered at the top of this form.Name* Prefix Mr.Ms.Other First Middle Last Suffix Maiden Name or AliasIf applicable.Email Phone*FaxAddress* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Date of Birth* MM DD YYYY U.S. Citizen?*YesNoID Documents Required*Please attach a copy of your Social Security Card and federal government issued photo ID with alien ID number or federal EIN.Accepted file types: pdf, jpg, jpeg, bmp, gif, png, psp.Social Security Number*The Kentucky Department of Alcoholic Beverage Control requires each owner's social security number to be listed on the licensing application. We will keep all your information strictly confidential.State(s) of Residence Over the Past 5 Years*If you have lived in multiple states or countries, please list all including the months and years of residence. Example: Indiana (01/2012-06/2014); Kentucky (07/2014-present).Business Title(s)*Business Ownership Percentage*Please enter a number from 0 to 100.Criminal History*Have you been convicted of any felony in the past 5 years, or been convicted of a misdemeanor in any way related to alcohol or a controlled substance in the past 2 years?YesNoCriminal Conviction Details*Please provide a full explanation, including all charges and dates of convictions.Suspension, Denial, or Revocation History*Have you ever had a Kentucky alcoholic beverage license suspended, denied, or revoked?YesNoSuspension, Denial, or Revocation Details*Please provide a full explanation, including dates of suspension, denial, or revocation.Other Alcoholic Beverage License Ownership*Do you currently hold any other Kentucky alcoholic beverage licenses or have any interest in other businesses with Kentucky alcoholic beverage licenses?YesNoOther Alcoholic Beverage License Details*Second Business Owner*Is there a second business owner?YesNoSecond Owner InformationName* Prefix Mr.Ms.Other First Middle Last Suffix Maiden Name or AliasIf applicable.Email Phone*FaxAddress* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Date of Birth* MM DD YYYY U.S. Citizen?*YesNoID Documents Required*Please attach a copy of your Social Security Card and federal government issued photo ID with alien ID number or federal EIN.Accepted file types: pdf, jpg, jpeg, bmp, gif, png, psp.Social Security Number*The Kentucky Department of Alcoholic Beverage Control requires each owner's social security number to be listed on the licensing application. We will keep all your information strictly confidential.State(s) of Residence Over the Past 5 Years*If you have lived in multiple states or countries, please list all including the months and years of residence. Example: Indiana (01/2012-06/2014); Kentucky (07/2014-present).Business Title(s)*Business Ownership Percentage*Please enter a number from 0 to 100.Criminal History*Have you been convicted of any felony in the past 5 years, or been convicted of a misdemeanor in any way related to alcohol or a controlled substance in the past 2 years?YesNoCriminal Conviction Details*Please provide a full explanation, including all charges and dates of convictions.Suspension, Denial, or Revocation History*Have you ever had a Kentucky alcoholic beverage license suspended, denied, or revoked?YesNoSuspension, Denial, or Revocation Details*Please provide a full explanation, including dates of suspension, denial, or revocation.Other Alcoholic Beverage License Ownership*Do you currently hold any other Kentucky alcoholic beverage licenses or have any interest in other businesses with Kentucky alcoholic beverage licenses?YesNoOther Alcoholic Beverage License Details*Third Business Owner*Is there a third business owner?YesNoThird Owner InformationName* Prefix Mr.Ms.Other First Middle Last Suffix Maiden Name or AliasIf applicable.Email Phone*FaxAddress* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Date of Birth* MM DD YYYY U.S. Citizen?*YesNoID Documents Required*Please attach a copy of your Social Security Card and federal government issued photo ID with alien ID number or federal EIN.Accepted file types: pdf, jpg, jpeg, bmp, gif, png, psp.Social Security Number*The Kentucky Department of Alcoholic Beverage Control requires each owner's social security number to be listed on the licensing application. We will keep all your information strictly confidential.State(s) of Residence Over the Past 5 Years*If you have lived in multiple states or countries, please list all including the months and years of residence. Example: Indiana (01/2012-06/2014); Kentucky (07/2014-present).Business Title(s)*Business Ownership Percentage*Please enter a number from 0 to 100.Criminal History*Have you been convicted of any felony in the past 5 years, or been convicted of a misdemeanor in any way related to alcohol or a controlled substance in the past 2 years?YesNoCriminal Conviction Details*Please provide a full explanation, including all charges and dates of convictions.Suspension, Denial, or Revocation History*Have you ever had a Kentucky alcoholic beverage license suspended, denied, or revoked?YesNoSuspension, Denial, or Revocation Details*Please provide a full explanation, including dates of suspension, denial, or revocation.Other Alcoholic Beverage License Ownership*Do you currently hold any other Kentucky alcoholic beverage licenses or have any interest in other businesses with Kentucky alcoholic beverage licenses?YesNoOther Alcoholic Beverage License Details*Additional Business Owners*Are there more than three business owners? Please list the names and ownership percentages of these other owners in the "Additional Information" section below and we will get the relevant information for them a little later.YesNoLicensed Premises InformationBusiness' Other Alcoholic Beverage License Ownership*Does the business hold any other Kentucky alcoholic beverage licenses or have any interest in other businesses with Kentucky alcoholic beverage licenses?YesNoBusiness' Other Alcoholic Beverage License Details*Address of Premises to be Licensed* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Deed or Lease to the Premises*Attach a copy of the deed or lease to the premises. The document must fully signed and all attachments must be included (assignments, subleases, etc.).Accepted file types: pdf, jpg, jpeg, bmp, gif, png, psp.Premises on Street Level?*Are the premises to be licensed located on street level?YesNoPurchasing Existing Business?*Is this business acquiring an interest in or purchasing an existing/ongoing business at this premises?YesNoPurchasing Existing Business Details*What is the nature of the interest to be obtained? (list all that apply)InventoryFixtures and equipmentOwnership by purchase of sharesOwnership by purchase of assetsLeasesPremises Recently Licensed?*Has the premises been licensed to sell alcoholic beverages in the past 12 months?YesNoPremises Currently Licensed?*Are the premises currently licensed?YesNoType of Establishment*Grocery StoreGas Station/Convenience StoreRestaurantBarType of Beverages to be Sold*Select all that apply. Beer (malt beverages) Liquor (distilled spirits) Wine Type of Consumption Desired*Select all that apply. By the package (consumption off the premises) By the drink (consumption on the premises) Sampling Other Options Sought*Select all that apply. Sunday sales Supplemental bars (a separate license is required for each bar where alcoholic beverages will be sold by the drink) Extended hours Other Additional InformationPlease include any additional information you would like our attorneys to know.Disclaimer*Our attorneys may review the information you submit for the purposes described on this website. The use of this form for communication with our firm does not establish an attorney-client relationship. Our review of the information sent to us will not preclude us from representing any other client if confidential information is sent through this form.I agreeI do not agreeEmailThis field is for validation purposes and should be left unchanged.
