INSTRUCTIONS FOR COMPLETING DBPR ABT– 6010 DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO APPLICATION FOR CHANGES TO POOL BUYING GROUPS Application begins on page 3 If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation at (850) 488-8284. Please send your completed application to: Department of Business and Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-1021 Attention: Pool Buying Section GENERAL INSTRUCTIONS Please complete all information. Incomplete applications will be returned. All questions are applicable and must be answered fully and truthfully. You must provide an original and a copy of the application. The copy of this application will be returned indicating the final agency action and, if approved, a new member may participate in pool purchases. APPLICATION REQUIREMENTS Temporary Permits A copy of a temporary permit is required only if the applicant is adding a licensee operating on a temporary permit to the pool group. Signatures All signatures must be original. This form must be signed and dated by the authorized pool group agent. The pool group agent must have a current retail alcoholic beverage license and must be a member of the pool buying group. 1 American LegalNet, Inc. www.FormsWorkflow.com APPLICATION CHECKLIST Select the appropriate transaction below and comply with the corresponding application requirements. TRANSACTION Addition to Pool Group Deletion from Pool Group Change of Agent Mailing Address Change of Pool Buying Agent Change of Pool Name Change of Agreement Amendments APPLICATION REQUIREMENTS ‰ Complete DBPR ABT-6010 Division of Alcoholic Beverages and Tobacco Application for Changes to Pool Buying Groups ‰ Copy of a temporary permit if adding a licensee operating on a temporary permit ‰ Complete DBPR ABT-6010 Division of Alcoholic Beverages and Tobacco Application for Changes to Pool Buying Groups ‰ Complete DBPR ABT-6010 Division of Alcoholic Beverages and Tobacco Application for Changes to Pool Buying Groups ‰ Complete DBPR ABT-6010 Division of Alcoholic Beverages and Tobacco Application for Changes to Pool Buying Groups ‰ Complete DBPR ABT-6010 Division of Alcoholic Beverages and Tobacco Application for Changes to Pool Buying Groups ‰ Complete DBPR ABT-6010 Division of Alcoholic Beverages and Tobacco Application for Changes to Pool Buying Groups ‰ Copies of changes of Agreement Amendments 2 American LegalNet, Inc. www.FormsWorkflow.com DBPR ABT-6010 – Division of Alcoholic Beverages and Tobacco Application for Changes to Pool Buying Groups STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION 1940 North Monroe Street Tallahassee, FL 32399-0783 If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation at (850) 488-8284. Please send your completed application to: Department of Business and Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-1021 SECTION 1 - CHECK TRANSACTION REQUESTED Transaction Type: Addition to Pool Group Change of Pool Buying Agent Deletion from Pool Group Change of Pool Name Change of Agent Mailing Address Change of Agreement Amendments (Submit Copies of Changes) SECTION 2 - POOL BUYING GROUP INFORMATION Full Name of Pool Buying Group Group Number Mailing Address (Street or P.O. Box) City Pool Buying Agent’s Name Authorized Contact Person (if other than Pool Buying Agent) State Zip Code FL Phone Number ( ) Phone Number ( ) SECTION 3 –POOL BUYING GROUP ADDITIONS OR DELETIONS If adding a temporary license holder to the group, a copy of the temporary license must be attached Full Name of Licensee License Number Series/Type Trade Name (D/B/A) Permanent License Temporary License License Number Permanent License Temporary License License Number Full Name of Licensee Trade Name (D/B/A) Full Name of Licensee Trade Name (D/B/A) Addition Deletion Series/Type Permanent License Temporary License Trade Name (D/B/A) Addition Deletion Series/Type Permanent License Temporary License License Number Full Name of Licensee Addition Deletion Series/Type Addition Deletion (Attach additional sheets as necessary) 1 American LegalNet, Inc. www.FormsWorkflow.com SECTION 4 - CHANGES TO POOL BUYING GROUP Change of Pool Buying Agent (Enter New Agent’s Name and Information) Full Name of Licensee License Number Trade Name (D/B/A Permanent License Temporary License Change of Pool Buying Group Name New Pool Buying Group Name Change of Agent Mailing Address Change of Authorized Contact Mailing Address Street Address City County State FL AUTHORIZED SIGNATURE OF POOL AGENT Zip Code _________________________________________________________________ Date ______________ Authorized Signature of Pool Agent FOR DIVISION USE ONLY ‰ Approved ‰ Disapproved Reason for Disapproval: Date_________________ Initials________________ 2 American LegalNet, Inc. www.FormsWorkflow.com