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Application For Out-Of-State Producers Exporters Or Rectifiers Form. This is a Arizona form and can be use in Liquor Licenses And Control Statewide.
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Tags: Application For Out-Of-State Producers Exporters Or Rectifiers, LIC0112, Arizona Statewide, Liquor Licenses And Control
ARIZONA DEPARTMENT OF LIQUOR LICENSES & CONTROL
400 W Congress #521
Tucson AZ 85701-1352
(520) 628-6595
800 W Washington 5th Floor
Phoenix AZ 85007-2934
(602) 542-5141
APPLICATION FOR OUT-OF-STATE PRODUCERS
EXPORTERS OR RECTIFIERS
SECTION 1 This application is for a:
SECTION 2 Type of ownership:
New License (More than 50 cases per
calendar year)
New License (50 cases or less per
calendar year) (2L)
Agent Change
SECTION 3 Fees:
Individual
Partnership Name
Corporation Name
ALL OUT OF STATE LICENSES EXPIRE ON NOVEMBER 30,
FAILURE TO RENEW WILL RESULT IN LATE PENALTIES
A service fee of $25.00 will be charged for all dishonored checks (A.R.S. 44-6852)
FEES:
Regular Out-of-State:
Application Approval Date:
2L (50 cases or less per calendar year):
Dec. – May $150.00
Jun. – Nov. $137.50
Dec. – May $350.00
Jun. – Nov. $325.00
Annual Renewal $120.00
Agent Change $100.00
Annual Renewal $ 95.00
Agent Change $100.00
NOTE: If your license is approved before November 30, it is mandatory that the license be renewed for the subsequent year.
SECTION 4 Applicant:
1. Applicant/Agent's Name:
(Insert one name ONLY to appear on license)
Last
First
Middle
2. Business Name:
(Exactly as it appears on the exterior of premises)
3. Business Address:
(Do not use P.O. box Number
Street
City
State
Zip
City
State
Zip
4. Mailing Address:
(All correspondence will be mailed to this address)
5. Business Phone: (
6. Federal ATF Permit #:
)
Street
Residence Phone: (
)
Your State Liquor License #:
ATTACH A COPY OF YOUR LICENSE THAT PERMITS YOU TO DEAL IN SPIRITUOUS LIQUOR IN YOUR HOME STATE.
(Continued on back)
Lic0112 05/2004
Disabled individuals requiring special accommodations please call (602) 542-9027
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SECTION 5 All questions MUST be answered.
1. Have you EVER had an application for any business, professional, or liquor license rejected,
denied, suspended, or revoked?
YES
NO
2. Has anyone EVER filed suit or obtained a judgment against you in any Civil action, the subject
of which involved fraud or misrepresentation of a liquor license?
YES
NO
3. Have you EVER been charged with or convicted of a felony?
YES
NO
5. Are you familiar with Arizona State Liquor Laws and Regulations?
YES
NO
6. Do you agree to notify the Department of Liquor of any proposed change of ownership
or other changes prior to making any such changes?
YES
NO
7. Do you agree to keep all records, invoices, and other documents relating to the purchase,
sale, or delivery of spirituous liquor for a period of two years and to have them easily
accessible for examination?
YES
NO
8. Do you consent to an investigation of your background including all records of every kind
and description including police records and to waive any rights or causes of action that you
may have against the Department of Liquor Licenses and Control and any other individual or
agency disclosing or releasing said information to the Department?
YES
NO
4. If you answered 'YES' to questions 1, 2, or 3, give complete details:
(Attach additional sheets if necessary)
9. If you answered 'NO' to any of questions 5, 6, 7, or 8 give complete details:
(Attach additional sheets if necessary)
FALSE OR INCOMPLETE ANSWERS COULD RESULT IN CRIMINAL PROSECUTION AND THE DENIAL
OR SUBSEQUENT REVOCATION OF A LICENSE OR PERMIT.
I,
, being first duly sworn upon oath, hereby depose,
(Print Name)
swear and declare under penalty of perjury, that I am the APPLICANT making the forgoing application. I have read this
application and the contents and all statements are true, correct and complete.
State of
X
County of
The foregoing instrument was acknowledged before me this
(Signature)
Day
Month
Year
My commission expires on:
MM/DD/YY
Signature of NOTARY PUBLIC
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