Looking for a Tax Exempt Form Templates? Download it for free!

Form Dbpr Abt-6038 - Division Of Alcoholic Beverages And Tobacco Application For Tax Exempt Wine Permit Page 2

SECTION 3 – APPLICANT SIGNATURE

NOTARIZATION REQUIRED

Organization Name

STATE OF___________________

_________________________________________________

Applicant Signature

COUNTY OF_________________

_________________________________________________

Type or Print Name and Title

The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this ______ Day

of ________, 20___, By ____________________________________________ who is ( ) personally

known to me OR ( ) who produced ___________________________________________as identification.

________________________________________________ Commission Expires: ___________________

Notary Public

FOR DIVISION USE ONLY

Date___________________

Permit Number________________________________________________

The wines ordered under this permit are to be used for religious or sacramental purposes. This permit

allows continued purchases from any duly licensed wholesaler or retailer and is in effect until revoked by the

Division of Alcoholic Beverages and Tobacco.

Approved By: ________________________________________________

Form Dbpr Abt-6038 - Division Of Alcoholic Beverages And Tobacco Application For Tax Exempt Wine Permit Page 2