File Deactivation Form
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File Deactivation Form. This is a Arizona form and can be use in Liquor Licenses And Control Statewide.
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Tags: File Deactivation Form, LIC0050, Arizona Statewide, Liquor Licenses And Control
ARIZONA DEPARTMENT OF LIQUOR LICENSES & CONTROL
400 W Congress #521
800 W Washington 5th Floor
Tucson AZ 85701-1352
Phoenix AZ 85007-2934
(520) 628-6595
(602) 542-5141
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FILE DEACTI VATION FORM
Print and Use Black Ink Only
I.
TYPE OF ACTION
LICENSE SURRENDER, COMPLETE SECTION II, PUT REASON ON REVERSE.
APPLICATION WITHDRAWAL, COMPLETE SECTION II, PUT REASON AT BOTTOM OF FORM.
USE ADDITIONAL SHEET IF NECESSARY
II.
LICENSE DATA
LICENSE NUMBER
LICENSEE
BUSINESS NAME
MAILING ADDRESS
_____________________________________
SIGNATURE OF LICENSEE/APPLICANT
State of____________________County of
The foregoing instrument was acknowledged before me this
______ OF _____________,
DAY
MONTH
YEAR
_____________________________________
SIGNATURE OF NOTARY PUBLIC
III.
DISPOSITIONS
LETTER ATTACHED
REVOKED-ORDER #__________________
REVERTED-ORDER #_________________
IV.
My commission expires ______ OF _____________,
DAY
MONTH
YEAR
REVIEW
FAILED TO RENEW
APPLICATION DENIED #
APPLICATION WITHDRAWN
EMPLOYEE
DATE
RECEIVED BY
BACKGROUND INVEST. (Pending Apps Only)
LICENSING SUPERVISOR
LCS TECHNICIAN
LIQUOR BOARD
REASON FOR WITHDRAWAL
USE ADDITIONAL SHEET IF NECESSARY
**Disabled individuals requiring special accommodations, please call 542-9027
lic0050 05/2004
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