Declaration Of Age - Pennsylvania

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PLCB-931 10/15
BUREAU OF
DECLARATION OF AGE
PENNSYLVANIA
STORE OPERATIONS
LIQUOR CONTROL BOARD
DATE
I,
, hereby represent to
,
a Fine Wine and Good Spirts store employee or licensee of the Pennsylvania Liquor Control Board, that I am of full age
and discretion and over the age of 21 years, having been born on _____/_____/_____in,
City/State
This statement is made to induce said store or licensee above named to sell or otherwise furnish alcoholic beverages to the undersigned.
Serial Number of Identification Card
I UNDERSTAND THAT I AM SUBJECT TO CRIMINAL PENALTIES INCLUDING FINES, IMPRISONMENT AND/OR LOSS OF
DRIVING PRIVILEGES FOR ANY MISREPRESENTATION HEREIN.
SIGNATURE
WITNESS:
(Person Requesting Service)
NAME
ADDRESS
ADDRESS
The PLCB reserves the right to furnish the Declaration of Age card to any appropriate law enforcement agency.
Identification Shown ________________________________ Signature Compared - Yes _______No
Race ___________ Sex _____ Complexion __________ Hair Color _________ Weight ______ Height
Code Requested ____________Time_________ Reason Refused

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