INSTRUCTIONS FOR COMPLETING DBPR ABT – 6015 DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO APPLICATION FOR DELINQUENT RENEWAL 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 GENERAL INSTRUCTIONS Please complete all information. All questions are applicable and must be answered fully and truthfully. All signatures must be original. Contact Person All communications regarding your application will be sent to the applicant at the mailing address provided. If you would like us to communicate with someone other than the applicant, please provide the information for that person in the section labeled “License Information”. 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. 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. APPLICATION CHECKLIST TRANSACTION Delinquent Renewal Auth. 61A-3.0101, FAC APPLICATION REQUIREMENTS Complete DBPR ABT-6015 Division of Alcoholic Beverages and Tobacco Application for Delinquent Renewal 1 American LegalNet, Inc. www.FormsWorkFlow.com DBPR ABT-6015 – Division of Alcoholic Beverages and Tobacco Application for Delinquent Renewal STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION DBPR Form ABT-6015 Revised 09/2010 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 SECTION 1 - CHECK TRANSACTION REQUESTED Transaction Type: Alcoholic Beverage License Retail Tobacco Products Dealer Permit Wholesale Cigarette Exporter & Other Tobacco Products Permits SECTION 2 - LICENSE INFORMATION Business Name (D/B/A): Full Name of Licensee: (This is the name the license is issued in) Licensee ID Number: Location Address: City County License/Permit Number Series Contact Person State Zip Code Type Telephone Number - E-Mail Address SECTION 3 - DELINQUENT RENEWAL EXPLANATION I submit the following explanation for not having renewed during the renewal period: Auth. 61A-3.0101, FAC 1 American LegalNet, Inc. www.FormsWorkFlow.com SECTION 4 - AFFIDAVIT OF APPLICANT NOTARIZATION REQUIRED Business Name (D/B/A): “I, the undersigned individual, 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 request.” “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 correct.” 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 ABT District Office Received/Date Stamp Auth. 61A-3.0101, FAC 2 American LegalNet, Inc. www.FormsWorkFlow.com