REPRESENTATION AND STATEMENT OF AGE FOR PURCHASE OF ALCOHOLIC BEVERAGES I understand that misrepresentation of age to induce the sale, service or delivery of alcoholic beverages to me is cause for my arrest, prosecution and punishment which can result in: 1. payment of a fine not less than $500 – nor more than $1,000; 2. possible imprisonment up to 6 months; 3. mandatory loss or deferment of driver’s license privileges for 6 months; 4. a requirement to participate in an alcohol education or treatment program for a period not to exceed 6 months. Knowing the possible penalties for misstatement, represent and state for the purpose of inducing I hereby _____________________________________________ (Name of Licensee) _____________________________________________ (Address of Licensed Premises) to sell, serve or deliver alcoholic beverages to me, that I was born ________________________ (Month) ____________________ (Day) ___________ (Year) and I am _________________ years of age. Date_________________________ Signed___________________________ Address___________________________ ___________________________ American LegalNet, Inc. www.FormsWorkflow.com OTHER IDENTIFICATION PRESENTED: ♦ Non-Photo Driver’s License – Number and State _____________________________________________ ♦ Photo Driver’s License – Number and State _____________________________________________ ♦ County Photo ID – Number and County _____________________________________________ ♦ Credit Card – Company and Number _____________________________________________ ♦ Draft Registration – Number and Date _____________________________________________ ♦ Other – Specify _____________________________________________ Signature of person who witnessed completion of this statement by patron. ____________________________________________ (Signature) State of New Jersey Department of Law and Public Safety Division of Alcoholic Beverage Control 140 East Front Street, P.O Box 087 Trenton, NJ 08625-0087 07/03 American LegalNet, Inc. www.FormsWorkflow.com