I hereby apply for a License to serve, from date hereof to _(pick date)__, inclusive (unless sooner revoked), Fermented Malt beverages and Intoxicating Liquors, subject to the limitation imposed by Section 125.32(2) and 125.68(2) of the Wisconsin Statutes and all acts amendatory thereof and supplementary hereto, and hereby agree to comply with all laws, resolutions, ordinances and regulations, Federal, State or Local, affecting the sale of such beverages and liquors if a license be granted to me

I certify that I am _(Select Age)__ years of age and do not have an arrest or conviction record to SS 111.321, 111.322, and 111.335.