APPLICATION, CHANGE IN TRADE NAME OF ABC PERMITTED BUSINESS ALCOHOLIC BEVERAGE CONTROL PERMIT DEPARTMENT P.O. BOX 540 MADISON, MS 39130-0540 RETURN TO American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION INSTRUCTIONS Please read these instructions carefully prior to completing this application. The permit fee is a non-refundable $25.00. If you currently pay for your alcoholic beverages by certified funds, then you must submit certified funds for payment of this fee. This application is used for changing your current trade name. Any changes in ownership must be approved by the Department before the transfer in ownership actually occurs. If you have questions, contact the ABC Permit Dept. for further information. In addition to submitting this application, we need from you will need to present proof that you have filed an updated sales tax registration form 70-001 with the Department of Revenue to report the change in trade name. Last, review your application to be sure that you have completed it properly. Send your application to: Alcoholic Beverage Control Permit Department P.O. Box 540 Madison, MS 39130-0540 If you need assistance, call ABC Permit Dept. at (601) 856-1330 American LegalNet, Inc. www.FormsWorkFlow.com (REVISED 08/2013) PERMIT DEPT. USE ONLY AMT. OF CHECK CHECK NUMBER PERMIT NUMBER APPLICATION FOR TRANSFER IN TRADENAME OF ALCOHOLIC BEVERAGE RETAILERS PERMIT I________________________________________________________, currently doing business as and located at (city) (county) , ABC Permit Number ___________ , hereby submit application for a transfer in tradename to: I. Does applicant have, or has the applicant ever had, an interest in any other alcoholic beverage retailer's permit? If "yes", explain fully: Is the applicant indebted to the State of Mississippi for any taxes, fees or payment of penalties imposed by law or by any rule or regulation on the If "yes", explain fully: Department? List your Mississippi Sales Tax Number: List your Federal Tax ID Number (EIN) __________________________________ Have you filed an updated sales tax registration form 70-001 with the Department of Revenue to report the change in trade name? ________ II. III. IV. V. American LegalNet, Inc. www.FormsWorkFlow.com PERMITTEE CERTIFICATION AND OATH I, , certify under penalty of perjury that the organization applying for the Alcoholic Beverage retailer's permit does meet the qualifications of a permittee as described in Sections 67-1-5, 67-1-51, 67-1-55, and 671-69, of the Mississippi Code of 1972, Annotated. I affirm that this organization will comply fully with the Local Option Alcoholic Beverage Control Laws, Rules and Regulations in the purchase, sale, and handling of alcoholic beverages and will keep all records and make all reports and remittances as required hereby. I certify that the information presented on this application to be true and correct, to the best of my knowledge and belief. I also agree that making a material misrepresentation on this application shall be evidence of a lack of trustworthiness as contemplated by MS Code Ann. Section 67-1-57 and provide a basis for denial on this application. Date: (Signature) (Title) SWORN TO AND SUBSCRIBED before me, this the day of Notary Public , My Commission Expires: American LegalNet, Inc. www.FormsWorkFlow.com NOTICE Your permit & packet will be mailed immediately after approval. If you elect to pick up your permit at the Liquor Distribution Center, call the Permit Department at 601-856-1330 to make prior arrangements. APPLICATION CHECK LIST Have you: ____included the $25.00 processing fee? ____completed the application for transfer? ____signed the certification and had your signature notarized? ____filed an updated sales tax registration form 70-001 with the Department of Revenue to report the change in trade name? American LegalNet, Inc. www.FormsWorkFlow.com