Record Of Wine Or Malt Beverage Delivery
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Record Of Wine Or Malt Beverage Delivery Form. This is a Oregon form and can be use in Liquor Control Commission Statewide.
Loading PDF...
Tags: Record Of Wine Or Malt Beverage Delivery, Oregon Statewide, Liquor Control Commission
OREGON LIQUOR CONTROL COMMISSION
RECORD OF WINE OR MALT BEVERAGE DELIVERY
Please Print or Type
Licensee ____________________________________________________________
Trade Name _________________________________________________________
Date of Request: ______________________________________________________
I delivered malt beverages or wine to:
Name _____________________________________________
Address ___________________________________________
Date & Time ________________________at ______________
I verified the age of this person (if they looked under 26 years old) by one of the following methods.
1. Driver's License Number _____________________ State ___________
2. State-issued Identification Card Number ________________________ State __________
3. Completed S-146 card attached.
Brand of Alcohol
Quantity
Price (alcohol)
Price (food)
[same day delivery only]
_________________________
___________
___________
_________
_________________________
___________
___________
_________
_________________________
___________
___________
_________
I certify that I delivered to the above-named person and that he/she is at least 21 years of age and
is not visibly intoxicated.
_____________________________________
Common Carrier Delivery Person
_________________________
Common Carrier Company
_____________________________________
Service Permittee
_________________________
Service Permit Number
1-800-452-OLCC (6522)
www.olcc.state.or.us
(rev. 08/04)
American LegalNet, Inc.
www.FormsWorkflow.com
