INSTRUCTIONS FOR COMPLETING DBPR ABT– 6001 DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO ALCOHOLIC BEVERAGE LICENSE AND RETAIL TOBACCO PRODUCTS DEALER PERMIT APPLICATION If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation or your local district office. Please submit your completed application and required fee(s) to your local district office. This application may be submitted by mail, through appointment, or it can be dropped off. A District Office Address and Contact Information Sheet can be found on AB&T’s page of the DBPR web site at the link provided below. http://www.myflorida.com/dbpr/abt/district_offices/licensing.html GENERAL INSTRUCTIONS Submitting Your Application Applications for alcoholic beverage licenses and retail tobacco products dealer permits are filed with the Division of Alcoholic Beverages and Tobacco. Please complete all information. All questions must be answered fully and truthfully. You must provide an original application and supporting documentation. All signatures must be original. If eligible, a temporary license may be purchased. Note: When applicable, you must submit a legible and executed copy of the following: Right of Occupancy (lease or deed must be in the entity applying for the license), Purchase Agreements, Franchise Agreements, Management Contracts, Service Agreements, and any agreements which require a percentage payment from the business operation, Certified Copy of Death Certificate, Letters of Administration, Certificate of Title, Certified Copy of All Court Orders pertaining to the alcoholic beverage license. Contact Person All communications regarding your application and invoices for payments of initial and renewal fees will be sent to the applicant at the mailing address provided. If you would like us to communicate with someone other than the applicant regarding deficiencies, please provide the information for that person in the “License Information” section. If you have appointed a person to act on your behalf and make changes to the application paperwork, please provide a copy of the Power of Attorney indicating such person is authorized to make changes on your behalf. If you have appointed an attorney to act on your behalf and make changes to the application paperwork, please provide a copy of the letter of representation. APPLICATION REQUIREMENTS FOR COMPLETING THIS APPLICATION License Types Refer to the “Alcoholic Beverages and Tobacco” page on the Department of Business and Professional Regulation’s Internet site for the License Type data chart. This is provided to guide applicants in knowing how each license type is defined in order to clarify which license type suits their needs. Zoning Approval Zoning approval is executed by the city or county zoning authority in which the business to be licensed is located. Zoning approval is required on all new and change of location applications unless the applicant is a state college or university located on State owned property. Zoning approval may also be required for certain change or increase in series applications. Zoning approval is not required on new applications for 1APS licenses unless required pursuant to a Special Act for the county in which you are applying. Applications must be submitted within 180 days of receiving this approval. Department of Revenue Clearance Department of Revenue clearance is required on applications for all new, transfer, change of location, and correction of information applications which change the licensee’s name. Applications must be submitted within 90 days of receiving this approval. Auth. 61A-5.010 & 61A-5.056, FAC 1 American LegalNet, Inc. www.FormsWorkFlow.com Health Approval Health approval is required on all applications for consumption on the premises. Businesses that serve food or are located on premises licensed by the Division of Hotels and Restaurants, must obtain approval from that division. Businesses that do not serve food must contact the County Health Authority or the Department of Health. Food service establishments located in grocery and convenience stores, bakeries or delicatessens must contact the Department of Agriculture and Consumer Services. Applications must be submitted within 90 days of receiving this approval. Affidavit of Applicant Read and sign in the presence of a notary. The affidavit must be signed by the individual applicant, a partner of each general partnership, a general partner of each general partnership of a limited partnership, a managing member or manager of a limited liability company, or one of the officers of a corporate applicant. Fingerprints Fingerprints must be submitted by each sole proprietor, all partners, officers, directors, individual share holders owning more than ½ of 1 percent of stock in non-public corporations, general partners of general partnerships, general partners of a limited partnership, managing members or managers of a limited liability company, and persons directly interested and receiving financial proceeds from the business. Applicants must use a Livescan vendor that has been approved by the Florida Department of Law Enforcement to submit their fingerprints to the department. Costs associated with the fingerprint process will be collected by the vendor. Vendor options and contact information can be viewed at Livescan Device Vendors List (http://www.fdle.state.fl.us/Content/getdoc/04833e12-3fc6-4c03-9993379244e0da50/livescan.aspx). Please ensure that the Originating Agency Identification (ORI) number for the Division of Alcoholic Beverages and Tobacco is provided to the vendor when you submit your fingerprints. The ORI number is FL920150Z. If you do not provide the ORI number, or if you provide an incorrect ORI number to the vendor, the Department of Business and Professional Regulation will not receive your fingerprint results. Out of State Alcoholic Beverage and Tobacco Applicants only: Your fingerprint card can be obtained from the Department of Business and Professional Regulation by contacting the Division of Alcoholic Beverages and Tobacco at 850.488.8284, or one of the division’s district offices. A listing of the district offices on the web can be found at http://www.myflorida.com/dbpr/abt/district_offices/licensing.html. Out of state applicants must be fingerprinted by a law enforcement agency on cards provided by the division (note: law enforcement agencies may charge for this service). The Division of Alcoholic Beverages and Tobacco has a unique ORI number that is required for processing the fingerprints back to the division, therefore, you must contact one of our offices to make a request for a card to be mailed to you. Once your fingerprint card is received, you may then go to a local law enforcement office in your area to have your fingerprints rolled onto the card. Other information will be completed at the local law enforcement agency. For all programs, the completed card must be mailed to Pearson VUE at: FLDBPR, Florida Fingerprinting Program, Prints Inc. 119 East Park Avenue, Tallahassee, FL 32301 where the fingerprint card will be scanned. Prior to mailing your fingerprint card, you must complete the following steps in order to make advance payment of $54.50 (do not send any money to PrintsInk, please follow the procedure below): OUT OF STATE LIVESCAN FINGERPRINTING REGISTRATION DIRECTIONS with Pearson VUE and or its subcontractor Morpho Trust (formerly known as L-1) 1. Log onto the Pearson VUE website at https://pearson.ibtfingerprint.com/ 2. Select Continue in English 3. Enter your legal first and last name. 4. Choose your agency from the drop down list 5. Select Pay For Ink Card Submission 6. Complete all of the required demographic information 7. Once you have entered your information select “Send” at the bottom of the page and you will be provided a verification page. You should verify that all the information you provided is correct and that you are being printed for the correct agency. 8. If everything is correct select “Go” at the top of the page and you have completed the entering of the required demographic information. Auth. 61A-5.010 & 61A-5.056, FAC 2 American LegalNet, Inc. www.FormsWorkFlow.com 9. Choose your form of payment the option and then “Select”. At this time you will be able to enter either your credit/debit card information, or e-check information. 10. Print the confirmation page. NOTE: you MUST include a copy of the confirmation page in the package with the fingerprint card sent to Prints Ink. Failure to provide the confirmation page may cause a delay in processing your fingerprint card. PLEASE NOTE: Failure to follow these instructions and make payment will result in your fingerprint card being returned to you and delay the processing of your fingerprints. To check on the status of your card, please call 1-800-528-1358 and not PrintsInk. Note: If you are a current licensee you are not required to submit a new set of fingerprints with your application unless you have been arrested since your prior submission of fingerprints to the division. If you are not a current licensee but have been fingerprinted for this division in the past three (3) years, and you have not been arrested since that time, you are not required to submit new fingerprints unless the prior application was withdrawn or non-consummated. Social Security Number Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless a Federal statute specifically requires it or allows states to collect the number. In this instance, disclosure of social security numbers is mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and sections 409.2577, 409.2598, and 559.79, Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and are used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec. 317. The State of Florida is authorized to collect the social security number of licensees pursuant to the Social Security Act, 42 U.S.C. 405(c)(2)(C)(I). This information is used to identify licensees for tax administration purposes. Surety Bond Surety bonds are required on all new applications for manufacturers, wholesale distributors of alcoholic beverages, wholesale distributors of cigarettes, and other tobacco products. A surety bond or a rider to the original bond must be submitted on any change of business name, change of location or change of ownership name application by the aforementioned. Contact the division's Auditing Office for further information. You may wish to have Auditing review your surety bond prior to submitting this application. Registration of Legal Entity All corporations, domestic or foreign; general partnerships; limited liability companies; and limited partnerships are required to be registered with the Florida Department of State, Division of Corporations. If you have not already registered, you will need to contact the Department of State at (850) 488-9000 or www.sunbiz.org for further information. Your application will be considered incomplete without this active registration. Related Party Personal Information This section of the application must be completed with original signatures for each applicant or person(s) directly connected with the business, unless they are current licensees. This will include the sole proprietor, all partners, officers, directors, individual share holders owning more than ½ of 1 percent of stock in non-public corporations, all partners of each general partnership, all general partners of a limited partnership, all managing members or managers of a limited liability company, and persons directly interested and receiving financial proceeds from the business. It is important that each individual discloses any arrests they have had within the past 15 years, even if they were charged, but not formally arrested, and regardless of the disposition. Copy of Arrest Disposition If the applicant answers “yes” to any of the criminal background questions asked in this application, provide a copy of the Arrest Disposition to ensure the applicant is qualified, pursuant to Statute and Rule. Auth. 61A-5.010 & 61A-5.056, FAC 3 American LegalNet, Inc. www.FormsWorkFlow.com Mitigation for Moral Character If the applicant is required to submit an arrest disposition, they may also be required to submit mitigation under the moral character rule. A copy of the rule and requirements can be found on AB&T’s page of the DBPR web site. Direct Interest A direct interest is a person or entity having an interest with the applicant in the business sought to be licensed and, includes but is not limited to: 1. an interest which is created by virtue of the interested party deriving revenue from the license; 2. a person or entity having the right to receive revenue based on a contractual relationship related to the control of the sale of alcoholic beverages, the terms of which, are contrary to 561.17, Florida Statutes, or 61A-3.017, Florida Administrative Code; 3. a person or entity who has a right to a percentage payment from the proceeds of the business, either by lease or otherwise. A direct interest does not include any person that derives revenue from the license solely through a contractual relationship with the licensee, the substance of which is not related to the control of the sale of alcoholic beverages, or is specifically exempt by statute or rule. Federal Employer's Identification Number (FEIN) All licensees who pay wages to one or more employees must have a Federal Employer's Identification Number. Contact the Internal Revenue Service (IRS) at 1-800-829-3676 and request Form #SS4. Club Licenses Applicants for club licenses must submit club by-laws and articles of incorporation. In addition, certain clubs must show proof of active existence for a minimum of two years, except as exempt by Chapter 565.02(4), F.S. Sketch of Premises A complete sketch of the premises, drawn in ink or computer generated (letter size) which includes all walls, doors, counters, sales areas, storage areas, etc. No architectural drawings are accepted. APPLICATION CHECKLIST TRANSACTION APPLICATION REQUIREMENTS New License ‰ Pay $100 or ¼ of the annual license fee, whichever is greater, if requesting a temporary license (make check payable to the Division of Alcoholic Beverages and Tobacco) ‰ Complete DBPR ABT-6001 Application for Alcoholic Beverage License and Tobacco Permit ‰ Submit fingerprint receipt, if applicable ‰ Copy of the Arrest Disposition, if applicable ‰ Mitigation for Moral Character, if applicable ‰ All new applications for manufacturers and wholesale distributors of alcoholic beverages must complete the DBPR ABT-6032 Surety Bond form ‰ Right of Occupancy Auth. 61A-5.010 & 61A-5.056, FAC 4 American LegalNet, Inc. www.FormsWorkFlow.com DBPR ABT-6001 – Division of Alcoholic Beverages and Tobacco Application for New Alcoholic Beverage License and Tobacco Permit STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION DBPR Form ABT-6001 Revised 09/2012 NOTE – This form must be submitted as part of an application packet If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation or your local district office. Please submit your completed application to your local district office. This application may be submitted by mail, through appointment, or it can be dropped off. A District Office Address and Contact Information Sheet can be found on AB&T’s page of the DBPR web site at the link provided below. http://www.myflorida.com/dbpr/abt/district_offices/licensing.html License Series Requested Child License Requested SECTION 1 - CHECK LICENSE CATEGORY Type/Class Requested Do you wish to purchase a Temporary License? Yes No Number of Child Licenses Requested Retail Alcoholic Beverages Beer/Wine/Liquor Wholesaler Alcoholic Beverage Manufacturer Retail Tobacco Products (must check one or more of the below) Pipes Over the Counter Vending Machine Passenger Waiting Lounge SECTION 2 – LICENSE INFORMATION If the applicant is a corporation or other legal entity, enter the name and the document number as registered with the Florida Department of State Division of Corporations on the line below. FEIN Number Business Telephone Number E-Mail Address Full Name of Applicant: (This is the name the license will be issued in) Department of State Document # Business Name (D/B/A) Location Address (Street and Number) City County State FL Zip Code State Zip Code Mailing Address (Street or P.O. Box) City Contact Person Telephone Number ext. E-Mail Address Mailing Address (Street or P.O. Box) City State Zip Code ABT District Office Received / Date Stamp Auth. 61A-5.010 & 61A-5.056, FAC 1 American LegalNet, Inc. www.FormsWorkFlow.com SECTION 3 – RELATED PARTY PERSONAL INFORMATION This section must be completed for each person directly connected with the business, unless they are a current licensee. 1. Business Name (D/B/A) 2. Full Name of Individual Home Telephone Number Race Sex Height Date of Birth Weight Social Security Number* Hair Color 3. Are you a U.S. citizen? Yes No If no, immigration card number or passport number: 4. Eye Color Home Address (Street and Number) City 5. State Zip Code Do you currently own or have an interest in any business selling alcoholic beverages, wholesale cigarette or tobacco products, or a bottle club? Yes No If yes, provide the information requested below. The location address should include the city and state. Business Name (D/B/A) License Number Location Address 6. Have you had any type of alcoholic beverage, or bottle club license, or cigarette, or tobacco permit refused, revoked or suspended anywhere in the past 15 years? Yes No If yes, provide the information requested below. The location address should include the city and state. Business Name (D/B/A) Date Location Address 7. Have you been convicted of a felony within the past 15 years? Yes No If yes, provide the information requested below and provide a Copy of the Arrest Disposition, as requested in the Application Requirements checklist. Date Location Type of Offense 8. Have you been convicted of an offense involving alcoholic beverages anywhere within the past 5 Yes No years? If yes, provide the information requested below and provide a Copy of the Arrest Disposition, as requested in the Application Requirements checklist. Date Location Type of Offense Auth. 61A-5.010 & 61A-5.056, FAC 2 American LegalNet, Inc. www.FormsWorkFlow.com 9. Have you been arrested or issued a notice to appear in any state of the United States or its territories Yes No within the past 15 years? If yes, provide the information requested below and a Copy of the Arrest Disposition. Attach additional sheet if necessary. Date Location Type of Offense 10. Are you an official with State police powers granted by the Florida Legislature? Yes No NOTARIZATION STATEMENT “I swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791, 562.45 and 837.06, Florida Statutes, that I have fully disclosed any and all parties financially and or contractually interested in this business and that the parties are disclosed in the Disclosure of Interested Parties of this application. I further swear or affirm that the foregoing information is true and correct.” STATE OF________________ COUNTY OF______________ _________________________________________________ APPLICANT SIGNATURE The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this ___________Day of_______________, 20_____, By _______________________________________who is ( ) personally (print name of person making statement) known to me OR ( ) who produced ___________________________________________as identification. _______________________________________________ Commission Expires: ___________________ Notary Public (ATTACH ADDITIONAL COPIES AS NECESSARY) *Social Security Number Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless a Federal statute specifically requires it or allows states to collect the number. In this instance, disclosure of social security numbers is mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and sections 409.2577, 409.2598, and 559.79, Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and are used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec. 317. The State of Florida is authorized to collect the social security number of licensees pursuant to the Social Security Act, 42 U.S.C. 405(c)(2)(C)(I). This information is used to identify licensees for tax administration purposes. Auth. 61A-5.010 & 61A-5.056, FAC 3 American LegalNet, Inc. www.FormsWorkFlow.com SECTION 4 – DESCRIPTION OF PREMISES TO BE LICENSED TO BE COMPLETED BY THE APPLICANT Business Name (D/B/A) 1. 2. 3. Yes Yes No No Is the proposed premises movable or able to be moved? Is there any access through the premises to any area over which you do not have dominion and control? Neatly draw a floor plan of the premises in ink, including sidewalks and other outside areas which are contiguous to the premises, walls, doors, counters, sales areas, storage areas, restrooms, bar locations and any other specific areas which are part of the premises sought to be licensed. A multi-story building where the entire building is to be licensed must show each floor plan. Auth. 61A-5.010 & 61A-5.056, FAC 4 American LegalNet, Inc. www.FormsWorkFlow.com SECTION 5 – APPLICATION APPROVALS Full Name of Applicant: (This is the name the license will be issued in) Business Name (D/B/A) Street Address City County State FL Zip Code ZONING TO BE COMPLETED BY THE ZONING AUTHORITY GOVERNING YOUR BUSINESS LOCATION A. The location complies with zoning requirements for the sale of alcoholic beverages or wholesale license. tobacco products pursuant to this application for a Series B. This approval includes outside areas which are contiguous to the premises which are to be part of the Yes No premises sought to be licensed and are identified on the sketch?” Check either: Location is within the city limits or Location is in the unincorporated county Signed____________________________________________________Date__________________ Title______________________________________________________ SALES TAX TO BE COMPLETED BY THE DEPARTMENT OF REVENUE The named applicant for a license/permit has complied with the Florida Statutes concerning registration for Sales and Use Tax. 1. This is to verify that the current owner as named in this application has filed all returns and that all outstanding billings and returns appear to have been paid through the period ending _____________ or the liability has been acknowledged and agreed to be paid by the applicant. This verification does not constitute a certificate as contained in Section 212.10 (1), F.S. (Not applicable if no transfer involved). 2. Furthermore, the named applicant for an Alcoholic Beverage License has complied with Florida Statutes concerning registration for Sales and Use Tax, and has paid any applicable taxes due. Signed____________________________________________________Date_____________________ Title____________________________________________ Department of Revenue Stamp HEALTH TO BE COMPLETED BY THE DIVISION OF HOTELS AND RESTAURANTS OR COUNTY HEALTH AUTHORITY OR DEPARTMENT OF HEALTH OR DEPARTMENT OF AGRICULTURE & CONSUMER SERVICES The above establishment complies with the requirements of the Florida Sanitary Code. Signed_______________________________________________________Date____________________ Title________________________________________________ Agency____________________________ Auth. 61A-5.010 & 61A-5.056, FAC 5 American LegalNet, Inc. www.FormsWorkFlow.com SECTION 6 – CONTRACTS OR AGREEMENTS Business Name (D/B/A) These questions must be answered about this business for every person or entity listed as the applicant and copies of agreements must be submitted with this application. If the management, service, or other contractual agreement gives a person or entity control of the licensed premises or the sale of alcoholic beverages, disclosure of those persons must be made in the section labeled “DIRECT INTEREST” in the DISCLOSURE OF INTERESTED PARTIES section. They must also submit fingerprints and a related party personal information sheet. 1. Yes No Is there a management contract, franchise agreement, or service agreement in connection with this business? 2. Yes No Are there any agreements which require a payment of a percentage of gross or net receipts from the business operation? 3. Yes No Have you or anyone listed on this application, accepted money, equipment or anything of value in connection with this business from a manufacturer or wholesaler of alcoholic beverages? SECTION 7 – APPLICANT ENTITY FELONY CONVICTION Has the applicant entity been convicted of a felony in this state, any other state, or by the United States in the last 15 years? Yes No If the answer is “Yes,” please list all details including the date of conviction, the crime for which the entity was convicted, and the city, county, state and court where the conviction took place. (Attach additional sheets if necessary) Auth. 61A-5.010 & 61A-5.056, FAC 6 American LegalNet, Inc. www.FormsWorkFlow.com SECTION 8 – SPECIAL LICENSE REQUIREMENTS (DOES NOT APPLY TO BEER AND WINE LICENSES) Business Name (D/B/A) Please check the appropriate “Special Alcoholic Beverage License” box of the license for which you are applying. Fill in the corresponding requirements for each Special License type. Quota Alcoholic Beverage License Club Alcoholic Beverage License Special Alcoholic Beverage License , Florida Statutes or Special Act, and as such we This license is issued pursuant to acknowledge the following requirements must be met and maintained: Please initial and date: Applicant’s Initials____________________________________ Date______________________________ Auth. 61A-5.010 & 61A-5.056, FAC 7 American LegalNet, Inc. www.FormsWorkFlow.com SECTION 9 – DISCLOSURE OF INTERESTED PARTIES Note: Failure to disclose an interest, direct or indirect, could result in denial, suspension and/or revocation of your license. Business Name (D/B/A) 1. When applicable, please complete the appropriate section below. Attach extra sheets if necessary. Title/Position Name Stock % CORPORATION (CORP/INC) President Vice President Secretary Treasurer Director(s) Stockholder(s) LIMITED LIABILITY COMPANY (LLC/LC) Managing Member(s) and/or Managers Members (must be printed if there are no managing members or managers) LIMITED PARTNERSHIP (LTD/LP/LTDLLP) General Partner(s) Limited Partner(s) Bar Manager (Fraternal Organizations of National Scope only): DIRECT INTEREST Name of Individual or Entity (If a legal entity, list name under which the entity does business and its principles) Title/Position Name Stock % 2. Are there any persons not listed above who have guaranteed or co-signed a lease or loan, or any person or entity who has loaned money to the business that is not a traditional lending institution? Yes No If yes, and the terms create a direct interest in the business, you must list the person(s) or entity and indicate which of the below applies. Each directly interested person must submit fingerprints and a related party personal information sheet. Copies of agreements must be submitted with this application. Interest Rate Name Guarantor Co-signer Lender (List) Auth. 61A-5.010 & 61A-5.056, FAC 8 American LegalNet, Inc. www.FormsWorkFlow.com SECTION 10 - AFFIDAVIT OF APPLICANT NOTARIZATION REQUIRED Business Name (D/B/A) “I, the undersigned individually, or if a registered legal entity for itself and its related parties, hereby swear or affirm that I am duly authorized to make the above and foregoing application and, as such, I hereby swear or affirm that the attached sketch is a true and correct representation of the premises to be licensed and agree that the place of business, if licensed, may be inspected and searched during business hours or at any time business is being conducted on the premises without a search warrant by officers of the Division of Alcoholic Beverages and Tobacco, the Sheriff, his Deputies, and Police Officers for the purposes of determining compliance with the beverage and retail tobacco laws.” “I swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791, 562.45 and 837.06, Florida Statutes, that the foregoing information is true and that no other person or entity except as indicated herein has an interest in the alcoholic beverage license and/or tobacco permit, and all of the above listed persons or entities meet the qualifications necessary to hold an interest in the alcoholic beverage license and/or tobacco permit.” STATE OF___________________ COUNTY OF_________________ _________________________________________________ APPLICANT SIGNATURE _________________________________________________ APPLICANT SIGNATURE The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this ___________Day of_______________, 20_____, By _______________________________________who is ( ) personally (print name(s) of person(s) making statement) known to me OR ( ) who produced ___________________________________________as identification. ________________________________________________ Commission Expires: ___________________ Notary Public Auth. 61A-5.010 & 61A-5.056, FAC 9 American LegalNet, Inc. www.FormsWorkFlow.com SECTION 11 - CURRENT LICENSEE UPDATE DATA SHEET This section is to be completed for all current alcoholic beverage and/or tobacco license holders listed on the application to ensure the most up to date information is captured. Business Name (D/B/A) Last Name First M.I. Current Alcohol Beverage and/or Tobacco License Permit/Number(s) Date of Birth Social Security Number* Street Address City State Last Name First Zip Code M.I. Current Alcohol Beverage and/or Tobacco License Permit/Number(s) Date of Birth Social Security Number* Street Address City State Last Name First Zip Code M.I. Current Alcohol Beverage and/or Tobacco License Permit/Number(s) Date of Birth Social Security Number* Street Address City State Last Name First Zip Code M.I. Current Alcohol Beverage and/or Tobacco License Permit/Number(s) Date of Birth Social Security Number* Street Address City State Last Name First Zip Code M.I. Current Alcohol Beverage and/or Tobacco License Permit/Number(s) Date of Birth Social Security Number* Street Address City Auth. 61A-5.010 & 61A-5.056, FAC State 10 Zip Code American LegalNet, Inc. www.FormsWorkFlow.com