Business Information Name Change Request
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Business Information Name Change Request Form. This is a Arizona form and can be use in Liquor Licenses And Control Statewide.
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Tags: Business Information Name Change Request, LIC0111, 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
BUSINESS INFORMATION/NAME CHANGE REQUEST
(No Fees Required)
1. License Number:
2. Licensee/Agent's Name:
Last
First
Middle
3. Current Business Name:
(Exactly as it appears on the license)
For all changes that apply to you, please check applicable boxes and complete:
New Business Name:
New Business Address:
NOTE: THIS IS NOT A LOCATION TRANSFER. THIS IS ONLY A LOCAL
GOVERNMENT OR U.S. POSTAL AUTHORIZED ADDRESS CHANGE.
DOCUMENTATION MUST BE ATTACHED.
Street
City
New Business Phone: (
)
State
State
New Home Phone (
Zip
Zip
)
New Mailing Address:
Street
City
Other (please explain):
(Attach additional sheet if necessary)
I,
, hereby declare that I am an AUTHORIZED PERSON filing this
(Print full name)
request. I have read this document 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)
Day
Month
Year
My commission expires on:
(Signature of NOTARY PUBLIC)
DEPARTMENT USE ONLY
Approved by:
Date:
*Disabled individuals requiring special accommodation, please call the Department.
LIC0111 05/2004
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