Dbpr Form Abt-6026 - Examination Application (Page 2 of 2) in pdf

SECTION 4 - COMPANY AFFILIATION

Business Name (D/B/A)

Have you in the past or presently, individually or as an officer or stockholder of a corporation in this state or any

other state:

Yes

a. Held stock or had any interest in, affiliated or connected with, directly or indirectly, any

business which sells any alcoholic beverages at retail?

Yes

b. Held stock or had any interest in, affiliated or connected with, directly or indirectly, any

business which manufactures, distributes, imports or exports any alcoholic

beverages?

If the answer to either of these questions is yes, list full particulars which include business names, cities, states,

and dates.

SECTION 5 - AFFIDAVIT OF APPLICANT

NOTARIZATION REQUIRED

Business Name (D/B/A)

"I, the undersigned individual, or if a corporation for itself, its officers and directors, hereby swear or affirm that I

am duly authorized to make the above and foregoing application and, as such hereby acknowledge that access

must be provided to authorized employees of the division to all business premises, inventories, and records,

including all records of transporter, warehouses, and exporters required by the Federal Government for the

purpose of conducting audits and inventories.

I swear under oath or affirmation under penalty of perjury as provided in Sections 559.791, 562.45 and 837.06,

Florida Statutes, that the foregoing information is true and correct and that no other person or entity except as

indicated herein has an interest in the export business and that all of the above listed persons or entities meet the

necessary qualifications to register as an exporter.”

STATE OF___________________

_________________________________________________

APPLICANT (Signature must be notarized)

COUNTY OF_________________

_________________________________________________

APPLICANT (Signature must be notarized)

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

Dbpr Form Abt-6026 - Examination Application Page 2