INSTRUCTIONS FOR COMPLETING DBPR ABT – 6031 DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO REQUEST FOR WITHDRAWAL OF APPLICATION 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 Please complete all information. All questions are applicable and must be answered fully and truthfully You must provide an original and a copy of the application. All signatures must be original. APPLICATION CHECKLIST Select the appropriate Transaction below and comply with the corresponding application requirements. TRANSACTION Withdrawal of Application APPLICATION REQUIREMENTS Complete DBPR ABT-6031 Division of Alcoholic Beverages and Tobacco Request for Withdrawal of Application form Return temporary permit, if applicable (optional) 1 American LegalNet, Inc. www.FormsWorkflow.com DBPR ABT-6031 – Division of Alcoholic Beverages and Tobacco Request for Withdrawal of Application 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. http://www.myflorida.com/dbpr/abt/district_offices/licensing.html SECTION 1 - APPLICATION INFORMATION I request the withdrawal of the following application: Temporary Permit Number Issued To Business Name Location Address (Street and Number) City County Is the temporary permit attached to this application? Yes State Zip Code No SECTION 2 - AFFIDAVIT OF APPLICANT NOTARIZATION REQUIRED 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 request. 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 2 American LegalNet, Inc. www.FormsWorkflow.com