APPLICATION FOR RENEWAL OF SOLICITOR REGISTRATIONBEER AND WINE SECTION 6606 TUSSING ROAD - P.O. BOX 4005 REYNOLDSBURG, OH 43068-9005 614-644-2411 SECTION I TO BE COMPLETED BY THE EMPLOYER SECTION II TO BE COMPLETED BY THE EMPLOYEE A $50.00 FEE IS DUE WITH EACH RENEWAL APPLICATION. MAKE CHECKS PAYABLE TO "DIVISION OF LIQUOR CONTROL" INSTRUCTIONS:SWORN STATEMENT:I ABOVE INFORMATION IS TRUE AND CORRECT.(EMPLOYER SIGNATURE)SECTION II EMPLOYEE / AGENT INFORMATION - TO BE COMPLETED BY THE EMPLOYEE / AGENT Have you been convicted of any offense other than a minor traffic violation within the past two years? IF YES, a full explanation and copy of CERTIFIED Journal Entry, sentence or disposition MUST be attached.FOR DIVISION USE ONLYID# DATE ISSUED CHECK# AMOUNT$ DLC 1608 FOR TTY USERS DIAL 1-800 -750-0750 EOE/ADA SERVICE PROVIDER REVISED 4/2019 EMPLOYER (company name):STREET ADDRESS:CITY:STATE:ZIP CODE:NAME:AREA CODE/ PHONE NUMBER: ADDRESS: NO YES Superintendent Approval/Denial:(Signature)(Date) ApprovedDenied SECTION I EMPLOYER INFORMATION - TO BE COMPLETED BY THE EMPLOYER , STATE THE ABOVE INFORMATION IS TRUE AND CORRECT. SWORN STATEMENT:I (EMPLOYEE SIGNATURE) PLACE OF BIRTH:DATE OF BIRTH:ZIP CODE:STATE:CITY: OTHER: PERMIT NUMBER:AREA CODE/ PHONE NUMBER:TITLE:CONTACT PERSON:, AM AN EMPLOYER OF THIS COMPANY AND STATE THE EMAIL ADDRESS: EMAIL ADDRESS: American LegalNet, Inc. www.FormsWorkFlow.com