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Form Dbpr Abt-6036 - Division Of Alcoholic Beverages And Tobacco Election Of Surcharge Calculation Method And Inventory Report Form Page 3

DBPR ABT-6036 – Division of Alcoholic Beverages and Tobacco Election of Surcharge

Calculation Method And Inventory Report Form

STATE OF FLORIDA

DEPARTMENT OF BUSINESS AND PROFESSIONAL

REGULATION

1940 North Monroe Street

Tallahassee, FL 32399-0783

NOTE: This form must be submitted as part of an

application packet

If you have any questions or need assistance in completing this application, please contact the

Department of Business and Professional Regulation or your local Auditing District Office. Please submit

your completed form and required information to your local Auditing District Office at the address listed in

the instructions.

SECTION 1 – APPLICATION TYPE

This application is for a:

New License

Change of Method

Transfer of a License

Nonprofit Organization Permit

SECTION 2 – SURCHARGE PAYMENT METHOD

I hereby elect to pay future surcharges based on the:

Purchases Method

Sales Method

SECTION 3 – APPLICANT INFORMATION

Full Name of Applicant

Business Name

Alcoholic Beverage License Number

Series

Mailing Address

City

State

Zip Code

Location Address

City

State

Zip Code

Contact Person

Business Phone Number

Home Phone Number

APPLICANT SIGNATURE

___________________________________________________________________

______________

Applicant Signature

Date

Form Dbpr Abt-6036 - Division Of Alcoholic Beverages And Tobacco Election Of Surcharge Calculation Method And Inventory Report Form Page 3

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