Dbpr Form Abt-6015 - Examination Application printable pdf download

DBPR ABT-6015 – Division of Alcoholic Beverages and Tobacco Application for Delinquent

Renewal

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. A District Office Address and Contact

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

SECTION 1 - CHECK TRANSACTION REQUESTED

Transaction Type:

Alcoholic Beverage License

Wholesale Cigarette Exporter & Other Tobacco Products Permits

SECTION 2 – LICENSE INFORMATION

Business Name

Issued To

Licensee ID Number

Location Address

City

County

State

Zip Code

License/Permit Number

Series

Type

Contact Person

Telephone Number

SECTION 3 – DELINQUENT RENEWAL EXPLANATION

I submit the following explanation for not having renewed during the renewal period:

SECTION 4 – AFFIDAVIT OF APPLICANT

NOTARIZATION REQUIRED

Trade 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 request.

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.

STATE OF___________________

_________________________________________________

APPLICANT SIGNATURE

COUNTY OF_________________

The foregoing was ( ) Sworn to and Subscribed

District Office Date Stamp

OR ( ) Acknowledged,

Before me this _______ Day of____________, 20______,

By____________________________ who is ( ) personally

known to me OR ( ) who produced

____________________________ as identification.

__________________________________________

Notary Public

Dbpr Form Abt-6015 - Examination Application

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