Dbpr Form Abt-6025 - Examination Application printable pdf download

DBPR ABT-6025 – Division of Alcoholic Beverages and Tobacco Reverter Affidavit for Quota Licenses

STATE OF FLORIDA

DEPARTMENT OF BUSINESS AND PROFESSIONAL

REGULATION

1940 North Monroe Street

Tallahassee, FL 32399-0783

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

Business and Professional Regulation or your local district office. Please submit your completed application to

your local district office. This application may be submitted by mail, through appointment, or it can be dropped off.

Address and Contact Information Sheet can be found on AB&T’s page of the DBPR web site at the link provided

below

LICENSE INFORMATION

License Number

Series

Licensee of Record

Transferee

Business Name (D/B/A)

Location Address

City

County

State

Zip Code

The application for transfer of the above referenced quota alcoholic beverage license has been

withdrawn by the applicant, disapproved, or non-consummated by the Division of Alcoholic

Beverages and Tobacco:

I certify that ownership of the licensed business reverted to me. I further certify that I am now

operating said business, either personally or by my authorized employees, and expect to

continue to operate said business until a transfer of the alcoholic beverage license is approved.

I certify that ownership of the licensed business reverted to me. I further certify that I will make

application to place the above referenced license in escrow; or if the license was in escrow at

the time of transfer, I will request an extension of the escrow period, if applicable.

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-6025 - Examination Application