Club Officers Statement Form. This is a Ohio form and can be use in Department Of Commerce Statewide.
Tags: Club Officers Statement, DLC 4050, Ohio Statewide, Department Of Commerce
FOR OFFICE USE ONLY OHIO DEPARTMENT OF COMMERCE - DIVISION OF LIQUOR CONTROL 6606 Tussing Road, P.O. Box 4005, Reynoldsburg, Ohio 43068-9005 NEW Telephone: (614) 644-2431 - http://www.com.state.oh.us TRANSFER PERMIT # CLUB OFFICERS STATEMENT SECTION A. Name of D4 Applicant DBA Name Permit Premises Address City State Zip Code OHIO Township, if in Unincorporated Area Federal Tax Identification No. LIST TOP FOUR OFFICERS: NAME OFFICE HELD RESIDENCE ADDRESS SSN DOB Affidavit Affidavit Being first duly sworn according to law, depose and say: *The above-listed individuals are the current elected and controlling officers of the Club. *The Club was organized solely for and in the interest of the membership of a reputable organization, and not for the profit of any person, firm, or company, either directly or indirectly. *Only members in good standing can and are permitted to exercise the privileges of the Club. *The telephone number of the Club premises is ____(_____)___________________________________________________ . *The Club was organized for the purpose of: Fraternal Social Recreational Benevolent Charitable Political *Membership in the Club is subject to the consent and approval of the membership at *The yearly initiation fee is $_______________________. *The dues of $______________ are payable Weekly Monthly Athletic Regular Quarterly Patriotic Special meetings. Semi-Annually Yearly. State of Ohio, __________________________County, ss: ____________________________________________________________________, being first duly sworn according to law, (Print Name) deposes and says that he/she is duly elected and qualified as the___________________________________________ of the ___________________________________________. (Club Name) __________________________________________ (Signed) (Office Held) TO BE COMPLETED BY NOTARY: Sworn to before me and subscribed in my presence this _____ day of ___________________ 20_______. (Date) (Month) (Year) Rev. 5/06 (Notary Public) (Expiration Date) American LegalNet, Inc. www.FormsWorkflow.com