INSTRUCTIONS FOR COMPLETING DBPR ABT – 6027 DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO APPLICATION FOR ESCROW OF AN ALCOHOLIC BEVERAGE LICENSE Application begins on page 2 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 Submitting Your Application This application is to be filed with the Division of Alcoholic Beverages and Tobacco. You must provide an original and a copy of this application. Please complete all information. All questions must be answered completely. If a question is not applicable, it is to be marked with the letters "N/A". This application is a sworn document and must be signed by all persons listed and attested to by a notary. APPLICATION CHECKLIST TRANSACTION Escrow of an Alcoholic Beverage License APPLICATION REQUIREMENTS Complete DBPR ABT-6027 Division of Alcoholic Beverages & Tobacco Application for Escrow of an Alcoholic Beverage License Pay $35 fee (make check payable to the Department of Business and Professional Regulation) 1 American LegalNet, Inc. www.FormsWorkflow.com DBPR ABT-6027 – Division of Alcoholic Beverages and Tobacco Application for Escrow of an Alcoholic Beverage License STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION 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. $35.00 processing fee must accompany your application. http://www.myflorida.com/dbpr/abt/district_offices/licensing.html License Number SECTION 1 - LICENSE INFORMATION Series Full Name of Applicant (if this is a corporation or other legal entity, enter the name as registered with the Secretary of State) Business Name (D/B/A) Current Location Address City State Zip Code Mailing Address City State Zip Code Reason for Escrow Request Anticipated Escrow Period TO BE COMPLETED BY THE DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO DISTRICT OFFICE PERSONNEL PRIOR TO BEING SIGNED BY APPLICANT This license was issued or transferred to the applicant entity on or before September 30, 1988. Therefore, as provided for in Section 561.29(1)(h), Florida Statutes failure to maintain licensed premises in an active manner in which the licensed premises are open for the bona fide sale of authorized alcoholic beverages during regular business hours of at least six (6) hours a day for a period of 120 days or more during any 12-month period, may result in this license being revoked or suspended. This license was issued or transferred to the applicant after September 30, 1988. Therefore, as provided for in Section 561.29(1)(i), Florida Statutes failure to maintain licensed premises in an active manner in which the licensed premises are open for the bona fide sale of authorized alcoholic beverages during regular business hours of at least eight (8) hours a day for a period of 210 days or more during any 12month period in a manner so as to maximize sales and tax revenues thereon, may result in this license being revoked or suspended. Applicant’s Initials: Date: 2 American LegalNet, Inc. www.FormsWorkflow.com SECTION 2 - AFFIDAVIT OF APPLICANT NOTARIZATION REQUIRED Business Name (D/B/A) "I, the undersigned individual, or if a corporation for itself, its officers and directors, hereby swear or affirm that I am duly authorized to make the above and foregoing application and, as such, I hereby acknowledge that the time frame for the activation of this license is understood as indicated hereon. 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___________________ _________________________________________________ APPLICANT (Signature must be notarized) COUNTY OF_________________ _________________________________________________ APPLICANT (Signature must be notarized) 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 District Office Received Date Stamp District Office Accepted Date Stamp 3 American LegalNet, Inc. www.FormsWorkflow.com