TRANSFER APPLICATION TRADENAME OF ALCOHOLIC BEVERAGE PERMIT RETURN TO ALCOHOLIC BEVERAGE CONTROL DIVISION PERMIT DEPARTMENT P.O. BOX 540 MADISON, MS. 39130-0540 American LegalNet, Inc. www.FormsWorkflow.com APPLICATION INSTRUCTIONS Please read these instructions prior to completing this application for a transfer in tradename of your permit. These instructions, along with information printed on certain forms, if followed, will allow you to file a complete document thus reducing the amount of processing time required to determine your eligibility. The application immediately follows these instructions. The permit transfer fee required is a non-refundable $25.00. If you are currently on certified funds then you will need to submit a cashier’s check or money order. If you are not on certified funds then you may send a personal check or company check. Complete the APPLICATION FOR TRANSFER. This form is essential for processing your transfer application correctly. Make sure that you have completed this form in its entirety. Additional information that we will need from you will be the following: A) You will need to obtain a "RIDER" from your insurance company changing the name on your bond. Last, review your application to be sure that you have completed it properly. Send your application forms to: ALCOHOLIC BEVERAGE CONTROL PERMIT DEPARTMENT P.O. BOX 540 MADISON, MS. 39130-0540 PLEASE ALLOW AMPLE TIME FOR PROCESSING If you need assistance call ABC Permit Department at (601) 856-1330 American LegalNet, Inc. www.FormsWorkflow.com (REVISED 4/96) PERMIT DEPT USE ONLY AMT. OF CHECK _______ CHECK NUMBER _______ PERMIT NUMBER ______ APPLICATION FOR TRANSFER IN TRADENAME OF ALCOHOLIC BEVERAGE RETAILERS PERMIT I,________________________________________________,doing business as ________________________________________________________________ ABC Permit No.__________and located at______________________________ (street) ____________________________________________________,hereby submit (city) (county) application for a transfer of 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: ______________________________________________________________________________ ______________________________________________________________________________ II. III. Is the applicant, indebted to the State of Mississippi for any taxes, fees or payment of penalities imposed by law or by any rule or regulation of the Commission?_________ If "yes" explain fully_______________________ __________________________________________________________ List your Mississippi Sales Tax Number:___________________________ PERMITTEE CERTIFICATION AND OATH I,______________________________________, certify under penalty of perjury that the organization applying for the Alcoholic Beverage Retailers Permit does meet the qualifications of a permittee as described in Sections 67-1-5, 671-51, 67-1-55, and 67-1-69, 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. Date:_______________________ __________________________ Signature __________________________ Title SWORN TO AND SUBSCRIBED before me, this the____day of _____________,____ My commission expires:_____________________ ____________________________ NOTARY PUBLIC American LegalNet, Inc. www.FormsWorkflow.com SPECIAL NOTICE The Commission Meetings are normally held each Wednesday at 10:00 A.M. You will not be notified of the date your application will be considered. Your permit will be mailed immediately after approval. If you elect to pick up your permit at the Liquor Distribution Center office, call 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? _ included a "rider" from your insurance company? _ signed the application where noted and have the signatures notarized? American LegalNet, Inc. www.FormsWorkflow.com