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Application For Registration Of A Retail Co-Op Agent Form. This is a Arizona form and can be use in Liquor Licenses And Control Statewide.
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Tags: Application For Registration Of A Retail Co-Op Agent, LIC0116, 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 REGISTRATION OF A RETAIL CO-OP AGENT
License #
1. Agents Name:
(Last)
(First)
(Middle)
2. Corporation Name:
3. Business Name:
4. Business Address:
(City)
(State)
(Zip)
5. Mailing Address:
(All correspondence will be mailed to this address)
6. Business Phone: (
7. Date of Birth:
(State)
Residence Phone: (
)
(City)
(Zip)
)
Place of Birth:
Height:
Weight::
Eyes:
Hair:
8. I hereby certify that if approved to operate as a registered retail agent, that I will comply with all laws and rules, promulgated
to control cooperative purchases.
I,
, hereby declare that I am the APPLICANT filing this
(Print full name)
application. I have read the application and the contents and all statements are true, correct and complete.
State of
County of
The foregoing instrument was acknowledged before me this
X
(Signature of APPLICANT)
day of
Day
,
Month
Year
My commission expires on:
(Signature of NOTARY PUBLIC)
A service fee of $25.00 will be charged for all dishonored checks (A.R.S. 44-6852)
*Disabled individuals requiring special accommodations, please call the Department.
LIC0116 05/2004
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AARIZONA DEPARTMENT OF LIQUOR LICENSES & CONTROL
400 W Congress #150
Tucson AZ 85701-1352
(520) 628-6595
800 W Washington 5th Floor
Phoenix AZ 85007-2934
(602) 542-5141
CO-OPERATIVE PURCHASE AGREEMENT
Name of Co-op:
Co-op #:
Agent:
Co-op Member:
Agent's Lic #:
Members Lic #:
Business Name:
Business Name:
Address:
Address:
City:
County:
City:
County:
Zip:
Phone #:
Zip:
Phone #:
1. All purchases by the Agent for the Co-op shall be from a licensed Arizona wholesaler.
2. The Agent shall furnish each of his Co-op Members a copy of the Master Invoice prepared by the wholesaler. Wholesaler may charge a
reasonable fee for extra copies of Invoice. The Invoice shall detail each Co-op Member's order, showing amount of order by brand and
cost by brand. The Agent shall not change or alter the Invoice in any manner whatsoever.
The Master Invoice shall indicate the total cost of all individual Member's orders and a copy shall be furnished to each Member. The
payment for the total order shall be made by the Agent. The Master Invoice shall dictate the specific discount for each "Co-operative
Purchase".
3. The accuracy of all orders placed by the Agent shall be the sole responsibility of the Agent. There shall be no exchanges of merchandise
after delivery. The Agent shall be responsible for any errors in the orders by Members of his Co-op. The Agent is responsible for the
fiscal operations of all Co-op purchases and shall retain all such records for a period of two years. All Co-op Members shall retain their
Invoices for a period of two years also.
4. Wholesalers shall deliver to the Agent's licensed premises or to an unlicensed storage premises under the absolute control of the Agent,
providing the Agent has received permission for the use of the unlicensed storage premises from the Director. Title to the merchandise
shall vest with the individual Co-op Member upon delivery to the Agent.
The Agent's fee for services rendered to the Co-op Member shall be $
per wholesaler Invoice.
Will
Will Not deliver merchandise to the Co-op Member. If the Agent does not deliver, the Co-op Member will
The Agent
obtain the merchandise from the designated storage location of the Agent.
The following provisions are agreed to between the Agent and the Co-op Member:
I,
, AND
(Printed name of AGENT)
,hereby declare that
(Printed name of CO-OP MEMBER)
being first duly sworn upon oath, hereby depose, swear and declare, under penalty of perjury, that I am the
applicantAPPLICANT making the foregoingfiling this agreement. I have read the agreement and that the agreement has been
read and that the contents thereof and all statements contained therein are true, correct and complete.
State of
X
County of
The foregoing instrument was acknowledged before me this
(Signature of AGENT)
Day
Month
Year
X
(Signature of CO-OP MEMBER)
(Signature of NOTARY PUBLIC)
My commission expires on:
LIC 0116 05/2004
*Disabled individuals requiring special accommodations, please call the Department.
American LegalNet, Inc.
www.FormsWorkflow.com
