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Reissue Application Form. This is a Indiana form and can be use in Alcohol And Tobacco Commission Statewide.
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Tags: Reissue Application, 47667, Indiana Statewide, Alcohol And Tobacco Commission
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
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