REISSUE APPLICATION INDIANA ALCOHOL & TOBACCO COMMISSION 302 W. Washington Street, Rm. E114 State Form 47667 (5-96) Indianapolis, IN 46204 Approved by State Board on Accounts 1996 Phone: (317) 232-2430 Web Page: http://www.IN.gov/atc Reissue Fee $10.00 FOR OFFICE USE ONLY Payment by mail may be money order, business check, or certified check. DO NOT SEND CASH OR PERSONAL CHECKS Cash Receipt #: __________________________ Date Reissued: __________________________ Expiration Date: __________________________ INFORMATION Type of Certificate to be Reissued (check one) : Name on Permit Alcoholic Beverage Employee Social Security Number (Mandatory) Permittee Address (number and street) State Tobacco Business Permit Number City Zip Daytime Telephone Number REASON FOR REISSUE Check Reason for Reissue: Original document never received (lost in mail) Original document lost Original document stolen Original document destroyed Articles of Amendment (name change, copy of articles of amendment must be attached) Articles of Merger (no change in ownership, copy of article of merger must be attached) SIGNATURE AND AFFIRMATION I understand that the original certificate is null and void upon reissuance, and if I recover the original certificate, I must forward it to the Indiana Alcohol & Tobacco Commission. I AFFIRM UNDER THE PENALTIES OF PERJURY THAT THE FOREGOING REPRESENTATIONS ARE TRUE AND CORRECT. Signature of applicant Printed or typed name of applicant Date American LegalNet, Inc. www.FormsWorkflow.com