Affidavit Of Lost Permit
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Affidavit Of Lost Permit Form. This is a Missouri form and can be use in Alcohol And Tobacco Control Statewide.
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Tags: Affidavit Of Lost Permit, Missouri Statewide, Alcohol And Tobacco Control
MISSOURI DEPARTMENT OF PUBLIC SAFETY
DIVISION OF ALCOHOL AND TOBACCO CONTROL
AFFIDAVIT OF LOST PERMIT
DATE
NAME OF CORPORATION, SOLE OWNER, PARTNERSHIP, OR LLC
LICENSE NO.
DOING BUSINESS AS
ADDRESS
CITY
STATE
being first duly sworn upon
his
her
their
ZIP
oath, state(s) that on
,
(MONTH, DAY, YEAR)
there was issued to
NAME OF CORPORATION, SOLE OWNER, PARTNERSHIP OR LLC
by the Supervisor of Alcohol and Tobacco Control of the State of Missouri,
STATE LICENSE NUMBER(S)
to sell
and that said original license was lost or destroyed on or about
LICENSE TYPE(S)
and that the circumstances under which the license was lost or destroyed are
(MONTH, DAY, YEAR)
as follows:
,
It is therefore requested that a duplicate license be issued in lieu thereof.
SIGNATURE OF MANAGING OFFICER, OWNER OR PARTNER
DATE
SIGNATURE OF PARTNER
DATE
NOTARY INFORMATION
NOTARY PUBLIC EMBOSSER
OR BLACK INK RUBBER
STAMP SEAL
STATE
COUNTY (OR CITY OF ST. LOUIS)
SUBSCRIBED AN SWORN BEFORE ME, THIS
DAY OF
NOTARY PUBLIC SIGNATURE
USE RUBBER STAMP IN
CLEAR AREA BELOW
YEAR
MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
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