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Schedule A – Information on the applicant
Alcohol permit application
Please consult the guide.
Section A – Identification of the applicant for a liquor permit
Name of applicant
Year
Date of birth,
if applicable
Month
Day
REQUIRED
Establishment
number
Québec Enterprise Number (NEQ)
Section B – Identification of all the partners, the shareholders holding at least 10% of the shares having
full voting rights, the directors and the person entrusted to manage the business
Surname
Given name
Indicate
the percentage
of the shares held
Specify the status, for example:
partner, shareholder, director
or manager of the business
If the space is insufficient, attach extra sheet.
Section C – Declaration of the applicant of the permit
1
2
Are you a Canadian citizen?
No
Yes
If no, are you a permanent resident?
No
Attach a copy of the document confirming your permanent resident status (IMM 1000, IMM 5292, permanent resident card).
Yes
Was any liquor permit you held or were responsible for ever suspended or revoked by the Régie?
If yes, give the name and address of the establishment concerned.
Yes
No
Name of the establishment
Number, street
3
City
Province
Postal code
Was any video lottery machine operator’s licence you held or were responsible
for suspended over the last five years?
No
Yes
Were you convicted of a criminal offence over the last five years?
No
Yes
Did you plead guilty to a criminal offence over the last five years?
No
Yes
If yes, please explain:
4
5
If you answered YES to question 4 or 5, please fill out lines 6, 7, 8 and 9.
6
7
8
9
10
Describe the nature of the offence:
Describe the sentence (conviction):
Year
Month
Day
Indicate the date when the sentence was handed down or guilty plea entered
Have you served your sentence?
No
Yes
Have you ever been convicted of or pleaded guilty to an offence?
If yes, specify the offence by checking the appropriate box and completing lines 11 and 12.
No
Yes
An Act respecting liquor permits and regulations thereto
Any act or regulation respecting the quality of the environment
An Act respecting offences relating to alcoholic beverages
The Youth Protection Act (article 135)
An Act respecting lotteries, publicity contests
and amusement machines
An Act respecting medical laboratories, organ, tissue, gamete
and embryo conservation and disposal of human bodies
Any act or regulation respecting health and safety
11
12
13
Nature of the offence:
Year
Month
Day
Date the sentence was handed down:
Answer the following question only if you are making an application for a video lottery machine operator’s licence (Schedule B)
Over the last five years preceding the date of this application, have you ever been convicted of or have pleaded guilty to a criminal offence or
to an offence punishable on summary conviction in respect of any provision of sections 201 to 209 of the Criminal Code pertaining to gaming
and betting?
No
Yes
Signature of the individual making this declaration
I, the undersigned,
declare that the information given herein is true.
surname and given name (in block letters)
In witness whereof I have signed,
Date
signature
year
month
day
Section reserved for the Régie des alcools, des courses et des jeux
(GP)
Vérification
RACJ-1042A.ang (11-02)
Initiales
Négative
Positive
(GI)
Initiales
Négative
Positive
Année
Date
Mois
Jour