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Name
<br />Type of License
<br />Account Number
<br />20. Club Liquor License applicants answer the following: Attach a copy of applicable documentation yes No
<br />a. Is the applicant cogeneration operated solely for a national, soaal, fraternal, patriotic, political or athletic purpose and not for pecuniary gam? ❑ X
<br />b. Is the applicant organization a regularly chartered bmnrh, lodge or chapter of a national aganizatlon we is operetetl saki for the El 0
<br />object of a patnom: or fretemal organization or society, bud not for pecuniary gain?
<br />c. Haw long has the club been incorporated?
<br />d. Has applicant occupied an establishment for Man years (tends years requiretl)that was Opereted solely for the reasons stated above? ❑ 0
<br />21. Bum -Pub, Distillery Pub or Vintners Restaurant applicants answer me following: ❑ 0
<br />a. Has the applicant recover! Or applied for a Fe clonal Permit? (Copy of permit or application must be attached)
<br />22. Campus Liquor Complex applicants answer the following:
<br />a. Is the applicant an institution of higher education? ❑ 0
<br />b. Is the applicant a person who contracts with the institution of higher education to provide food! services? ❑ 0
<br />If "yes" please provide a copy of the contract with the institution of higher education to provide food services.
<br />23. For all on -premises applicants.
<br />a. Hold and Restaurant, Lodging and Entertainment, Tavern License and Campus Liquor Complex, the Registered Manager must also submit an
<br />Individual History Record
<br />- DR 8404-I and fingerprint submitted to approved State Vendor through the Vendors website. See application checklist, Section IV, for details.
<br />b. For all Liquor L oonsetl Drugstores (LLDS) the Permigetl Manager must also submit an Manager Leant Application
<br />- DR 8000 and fingerprints.
<br />Last Name of Manager
<br />First Name of Manager
<br />Iglesias
<br />Barbara
<br />24. Does this manager ad as the manager of or have a financial interest in, any other liquor licensed establishment in the State of yes No
<br />Coleraine? If yes, provide name, type of license and account number ❑ 0
<br />25. Related Facility- Campus Liquor Complex applicants answer the following_ ❑ ❑X
<br />a. Is the related facility locatetl within the boundaries of the Campus Liquor Complex?
<br />R yes, please provitle a map of the geographical location within the Campus Liquor Complex_
<br />R no, this license type is net available for issues outside the geographical location of the Campus Liquor Complex_
<br />b. Designated Manager for Related Fealty Campus Liquor Complex
<br />Last Name of Manager
<br />First Name of Manager
<br />26. Tax Information . yes No
<br />a. Has the applicant, Including Its manager, partners, officer, directors, stockholders, members (LLC), managing members (LLC), or any ❑
<br />other person with a 10% or greater financial interest in the applicant, been found in final order of a taa agency to be delinquent in the
<br />Payment of any state or local taxes, penalties, Or interest related to a business?
<br />b. Has the applicant, Including its manager, partners, officer, directors, stockholders, members (LLC), managing members (LLC), or any ❑ 1]
<br />other person with a 10% or greater financial interest in the applicant failed to pay any fees or surcharges imposed pursuant to section
<br />44-3 03, C RS?
<br />27. R applicant is a corporation, partnership, association or limited liability company, applicant must led all Officers, Directors, General Partners,
<br />and Managing Members_ In ad itioq applicant must tic any stockholders, partners, or members with ownership of 10% or more in the
<br />applicant. All persons listed below must also attach tome DR 8404-I (Individual History Record), and make an appointment with an approved
<br />State Vendor through their website. See application checklist, Section IV, for details_
<br />Name
<br />Home Address, City B State
<br />DOB
<br />Position
<br />%Owned
<br />Barbara Iglesias
<br />556 Lincoln Ave Louisville Co 80027
<br />Managing Member
<br />95
<br />AM
<br />Name
<br />Home Address, City & State
<br />Position
<br />%Owned
<br />Robert Iglesias
<br />41 West Broad Oaks Houston Tx 77056
<br />Member
<br />5
<br />Name
<br />Home Address, City B State
<br />DOB
<br />Position
<br />%Owned
<br />Name
<br />Home Address, City B State
<br />DOB
<br />Position
<br />%Owned
<br />Name
<br />Home Address, City B State
<br />DOB
<br />Position
<br />%Owned
<br />"If applicant is owned 100% by a parent company, please list the designated principal officer on above.
<br />"Corporations - the Prescient, VicePresident, Secondary and Treasurer must be acoOurtetl for above (Include ownership penentage if applicable)
<br />"If total ownership pement ige disclosed here does not total 100%, applicant must check this box:
<br />0 Applicant aAinns that no individual other than these disclosed herein Owns 10% or more of the applicant and does not have financial interest in a
<br />pram Land liquor license pursuant to Article 3 or 5, C R S.
<br />
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