Agency Operations 6606 Tussing Road PO Box 4005 Reynoldsburg, OH 43068 - 900 5 LIQ - 18 - 0013 An Equal Opportunity Employer and Service Provider LESC 877 | 812 0013 FAX 614 | 728 1281 TTY/TDD 800 | 750 0750 www.com.ohio.gov Rev. 10/2018 Wholesale Transfer Request Liquor Agency Information Assigned Agency Information Proposed Agency Information Agency Number: Agency Number: Agency Street Address: Agency Street Address: City: ZIP: City: ZIP: Reason for Transfer Request (Please be specific): Permit Holder Information Permit Number: Address 1: Name of Applicant: Address 2: DBA: City: Phone Number: ZIP: Name (Please Print) Title Signature Date Please return request by ema il to liquoragencyhelp@com.state.oh.us . Please allow 7 to 10 busi ness days for processing . American LegalNet, Inc. www.FormsWorkFlow.com