Application For Replacement License-Permit Or Purchase Cards Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Application For Replacement License-Permit Or Purchase Cards Form. This is a Pennsylvania form and can be use in Liquor Control Board Statewide.
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Tags: Application For Replacement License-Permit Or Purchase Cards, PLCB-56, Pennsylvania Statewide, Liquor Control Board
PLCB-56 5/08
APPLICATION FOR
REPLACEMENT LICENSE, PERMIT
OR PURCHASE CARDS
COMMONWEALTH OF PENNSYLVANIA
PENNSYLVANIA
LIQUOR CONTROL BOARD
BUREAU OF LICENSING
10A
(SUBMIT ORIGINAL ONLY - SEE INSTRUCTIONS BELOW)
The undersigned holder hereby applies for replacement of:
LICENSE ONLY
PERMIT
LICENSE AND PURCHASE CARDS
PURCHASE CARDS (STORE DISCOUNT CARD AND LICENSEE DISCOUNT CARD)
1. TYPE OF LICENSE OR PERMIT
LICENSE OR PERMIT NO.
2. NAME OF LICENSEE OR PERMITTEE
LID NO.
3. ADDRESS OF PREMISES
(STREET, RURAL ROUTE, P.O. BOX NO.)
4. NAME OF MUNICIPALITY
(POST OFFICE)
TYPE OF MUNICIPALITY
CITY
BORO
TWP.
INC.
TOWN
(STATE)
(ZIP)
COUNTY
5. REASON FOR REQUIRING REPLACEMENT
SIGNATURE
TITLE
SIGNATURE
TITLE
HOME ADDRESS
PHONE
HOME ADDRESS
PHONE
(
)
(
DATE SIGNED
STORE STAMP (SEE INSTRUCTION 2)
)
DATE SIGNED
STATE STORE NO.
INSTRUCTIONS
1. A fee of ten dollars ($10.00) MUST ACCOMPANY THIS APPLICATION, made payable to "PLCB" or "Commonwealth
of Pennsylvania".
2. State Store stamp is not required unless application is filed with State Store; however, store number must be listed.
3. If licensee is a partnership, corporation or club, the signature of only one partner or secretary of the corporation or club
is required.
4. In answering Question 5 give complete details. If application is for Wholesale Purchase Permit Cards (store discount
card and licensee discount card), file application with the State Store where present store discount card is deposited.
New cards will be mailed directly to State Store.
Send the application packet to: Pennsylvania Liquor Control Board
Bureau of Licensing
P.O. Box 8940
Harrisburg, PA 17105-8940
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