Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Affidavit Form. This is a New Hampshire form and can be use in Liquor Commission Statewide.
Loading PDF...
Tags: Affidavit, New Hampshire Statewide, Liquor Commission
State of New Hampshire
Liquor Commission
Division of Enforcement & Licensing
AFFIDAVIT
This affidavit is filed with the Liquor Commission’s Division of Enforcement & Licensing in support of my ownership,
management control, employment by a business licensed, or applying for a license to sell alcoholic beverages and
tobacco under Chapter 178 of the Revised Statutes Annotated.
I,
being duly sworn do depose and say:
(Print Name)
1.
Business Trade Name:
Liquor Lic#
Address
(No. – Street)
(City / Town)
(State)
(Zip)
(No. – Street)
(City / Town)
(State)
(Zip)
(No. – Street)
(City / Town)
(State)
(Zip)
Mailing
Address
2.
3.
I live at:
I was born in
on
(POB: i.e. State, or Province if Canada, Country if foreign)
Home phone
I am
4.
Male
Female
(Date of Birth)
Race
(Age)
Soc. Sec #
I am not a citizen of the United States
If not a citizen, R.A. Document # or other Identification submitted
5.
I understand RSA 178:4 & RSA 179:23, IV, prohibit convicted felons from holding a license to sell alcohol or
assuming control of licensed premise. By signing this affidavit I swear this information is true and accurate
and that this document is signed under the penalty if false swearing (RSA 641:2)
6.
Have you ever been charged with a crime?
Yes
No
If yes, were you convicted of a felony?
Yes
No
7.
I am filing this document in support of my employment as a
Corporate Officer
POA
Person in Charge
Partner
LLC Member
Proprietor
LLC Manager
Manager
Title/Position
RSA 179:23, IV requires the licensee to designate one or more people to be in charge of the premise in the
licensee’ absence.
8.
I swear before the Justice of Peace or Notary Public that this information is true and accurate, and that this
document is signed under the penalty if false swearing (RSA 641:2)
Signature
Date
County
SS.
Personally appeared before me
and made oath that the same is true.
known to be the person who executed
(Affiant Name)
SEAL
L-002 (Reviewed 8/8/2012)
Date:
Justice of Peace / Notary Public
8/2006
American LegalNet, Inc.
www.FormsWorkFlow.com