INSTRUCTIONS FOR COMPLETING DBPR ABT – 6013 DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO APPLICATION FOR DISTRIBUTOR’S SALESPERSON OF WINE OR SPIRITS 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 and required fee(s) to: Department of Business and Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-1021 GENERAL INSTRUCTIONS Submitting Your Application Please complete all information. All questions are applicable and must be answered fully and truthfully. This is a sworn document. False answers could result in criminal prosecution, subject to fine and/or imprisonment and denial of your application. You must provide an original and a copy of the application and duplicate copies of all supporting documentation. All signatures must be original. APPLICATION REQUIREMENTS A check or money order in the amount of $50 must be submitted with your application. Affidavit of Applicant Read and sign in the presence of a notary. The affidavit must be signed by the individual applicant. Fingerprints Fingerprints must be submitted by each individual applicant, all corporate officers, all managing members, all general partners of a limited partnership, all partners of a general partnership, each individual stockholder owning more than .5 percent of stock, and all directors. Each applicant shall submit electronic fingerprints through the department’s vendor PearsonVue. Costs associated with the fingerprint process will be collected by PearsonVue. You may contact PearsonVue at www.pearsonvue.com or by calling 1.888.274.2020. At the time application is made to the Division of Alcoholic Beverages and Tobacco, you will need to submit your PearsonVue receipt. The receipt serves as proof of the fingerprint requirement and includes information necessary to process your application. Failure to provide this receipt will delay the processing and/or denial of your application. Note: If you are a current licensee or have been fingerprinted by this division in the past three (3) years, you are not required to submit this fingerprint information. 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, 1 American LegalNet, Inc. www.FormsWorkflow.com 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. Certified Copy of Arrest Disposition If the applicant answers “yes” to any of the criminal background questions asked in this application, provide a Certified Copy of the Arrest Disposition to ensure the applicant is qualified, pursuant to Statute and Rule. 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. APPLICATION CHECKLIST TRANSACTION Distributor’s Salesperson License APPLICATION REQUIREMENTS Pay $50 fee (make checks payable to the Department of Business and Professional Regulation) Complete DBPR ABT-6013 Division of Alcoholic Beverages and Tobacco Application for Distributor’s Salesperson of Wine or Spirits Certified copy of the Arrest Disposition, if applicable Mitigation for Moral Character, if applicable Contact the department’s vendor for electronic fingerprinting, PearsonVue at www.pearsonvue.com or call 1.888.274.2020 to arrange for fingerprinting. Submit the receipt issued by PearsonVue with your application. 2 American LegalNet, Inc. www.FormsWorkflow.com DBPR ABT-6013 – Division of Alcoholic Beverages and Tobacco Application for Distributor’s Salesperson of Wine or Spirits STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION 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 at (850) 488-8284. Please send your completed application and required fee(s) to: Department of Business and Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-1021 SECTION 1 – APPLICANT INFORMATION Full Name of Applicant Social Security Number* Race Sex Date of Birth Height Weight Eye Color Hair Color Current Mailing Address City State Zip Code Telephone Number SECTION 2 – EMPLOYER INFORMATION Employer’s Business Name Employer’s Beverage License Number Employer’s Telephone Number Employer’s Location Address City State Zip Code State Zip Code Employer’s Mailing Address City *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. 3 American LegalNet, Inc. www.FormsWorkflow.com SECTION 3 – APPLICANT BACKGROUND INFORMATION Applicant Name 1. Have you ever been arrested or issued a notice to appear in any state of the United States or its territories? If yes, list date, location, and type of offense in the spaces below and provide a Certified Copy of the Arrest Disposition. If you are a convicted felon and have had your civil rights restored in Florida, attach a Certified Copy. ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ___________________________________________________________________ 2. Are you an official with State police powers granted by the Florida Legislature? If yes, please provide the details: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 3. Do you currently have financial interest in any business selling alcoholic beverages? If yes, list business name, location and license number: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 4. Are you employed full or part-time or receiving any remuneration from any vendor licensed under the beverage laws of the State of Florida? If yes, list business name, location, and details: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 5. Have you ever had any type of alcoholic beverage, salesman's, cigarette, or tobacco permit refused, revoked or suspended anywhere? If yes, list business name, location and date: ____________________________________________________________________ ____________________________________________________________________ ___________________________________________________________ 4 Yes No Yes No Yes No Yes Yes No No American LegalNet, Inc. www.FormsWorkflow.com SECTION 4 - AFFIDAVIT OF APPLICANT NOTARIZATION REQUIRED Applicant Name The undersigned individual hereby authorizes the Division of Alcoholic Beverages and Tobacco, to examine and/or copy any and all records including, but not limited to, personal, financial or criminal data relating to the information contained herein, during normal business hours from this date forward. “I swear under oath or affirmation under penalty of perjury as provided in Sections 559.791, 562.45 and 837.06, Florida Statutes, that the foregoing information is true and correct.” STATE OF___________________ _________________________________________________ APPLICANT SIGNATURE COUNTY OF_________________ The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this __________Day of__________, 20______, By____________________________________________ who is ( ) personally known to me OR ( ) who produced ______________________________________________as identification. ________________________________________________ Commission Expires: ___________________ Notary Public FOR DIVISION USE ONLY – DO NOT WRITE BELOW THIS LINE File #:____________________________ License #:____________________________ Approved by:___________________________________________ Date:_____________ Fee:___________ Central Office Date Stamp 5 American LegalNet, Inc. www.FormsWorkflow.com