Fillable Printable Form 700306

Form 700306

Change In Governing People, Percentage

Owned and/or Stock/Unit Ownership

(this does not replace your annual report)

Please continue on to the next page.

* A different form is required to make changes to ofcers, members, managers or your Resident Agent with the Ofce of

the Secretary of State. Please contact them at [email protected] or 360-725-0377.

To receive this document in an alternate format, please call 1-800-647-7706. Teletype (TTY) users may use the Washington Relay Service by calling 711.

BLS 700-306 (10/12/17)

State of Washington

Business Licensing Service

PO Box 9034

Olympia WA 98507-9034

1-800-451-7985

bls.dor.wa.gov

UBI number

Liquor/Lottery license number

For validation only

03N-400-925-0003

Ownership type  Partnership  Corporation  LLC  LP/LLP/LLLP  Non Prot Corporation

Name UBI Number FEIN

( )

Company mailing address (Street or route) City

( )

State Zip code Company telephone number

Contact name (Last, First, Middle) Contact telephone number Contact email address

Stock ownership (if applicable)

At the completion of this change, the governing persons and/or stockholders will be:

Title examples: owner, partner, president, vice president, secretary, treasurer, member, manager, director

Name (Last, First, Middle) Title Social security number

Date of birth

( )

Home/business address (Street or route) City State Zip code Telephone number

Date became owner/ofcer Number of shares owned Percent owned Date(s) issued or enter “pending” if not yet issued

Name of spouse (Last, First, Middle)

Spouse social security number Spouse date of birth

Is this person related to other ofcers who own 10 percent or more? Yes No

(i.e. parent, stepparent, grandparent, spouse, children, brother, sister, stepchildren, adopted children or grandchildren)

Name (Last, First, Middle) Title Social security number Date of birth

( )

Home/business address (Street or route) City State ZIP code Telephone number

Date became owner/ofcer Number of shares owned Percent owned Date(s) issued or enter “pending” if not yet issued

Name of spouse (Last, First, Middle)

Spouse social security number Spouse date of birth

Is this person related to other ofcers who own 10 percent or more? Yes No

(i.e. parent, stepparent, grandparent, spouse, children, brother, sister, stepchildren, adopted children or grandchildren)

Total stock authorized: Number of shares issued: Par value per share:

Amount Due

Liquor........................ $75.00 Change in more than 10% of stock, election of new ofcers or

changes in members or managers.

Marijuana.................. $75.00

All other Licenses...... Required for all governing people and/or stock changes regardless of the

amount of percentage of ownership.

NO FEE

Make check payable to the Department of Revenue Total amount due (Add Row 1 and 2)

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Additional forms or documents may be required by the individual agency.

Liquor and Cannabis Board (360) 664-1600 • Lottery (360) 753-2155

Certication

Under penalty of perjury, I hereby certify there have been no changes in ofcers or stockholders that have not been

reported, and that each ofcer and stockholder is the real party in interest with respect to his/her position and is not

acting directly or indirectly as agent, employee or representative of any other person not reported. I certify on behalf of

the corporation that it is understood a misrepresentation of fact is cause for rejection of this application or revocation of

any license issued.

Print Name Title

Signature Date Phone #

To receive this document in an alternate format, please call 1-800-647-7706. Teletype (TTY) users may use the Washington Relay Service by calling 711.

BLS 700-306 (10/12/17)

Name (Last, First, Middle) Title Social security number

Date of birth

( )

Home/business address (Street or route) City State Zip code Telephone number

Date became owner/ofcer Number of shares owned Percent owned Date(s) issued or enter “pending” if not yet issued

Name of spouse (Last, First, Middle)

Spouse social security number Spouse date of birth

Is this person related to other ofcers who own 10 percent or more? Yes No

(i.e. parent, stepparent, grandparent, spouse, children, brother, sister, stepchildren, adopted children or grandchildren)

If necessary, attach additional sheets using the same format as shown above.

Removal of governing people

Name of governing person or stockholder Social security number Date of birth Title Removal Date

Name (Last, First, Middle) Title Social security number Date of birth

( )

Home/business address (Street or route) City State Zip code Telephone number

Date became owner/ofcer Number of shares owned Percent owned Date(s) issued or enter “pending” if not yet issued

Name of spouse (Last, First, Middle)

Spouse social security number Spouse date of birth

Is this person related to other ofcers who own 10 percent or more? Yes No

(i.e. parent, stepparent, grandparent, spouse, children, brother, sister, stepchildren, adopted children or grandchildren)

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