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Dbpr Form Abt-6007 - Division Of Alcoholic Beverages And Tobacco Request For Cancellation Of Permanent License

DBPR ABT-6007 – Division of Alcoholic Beverages and Tobacco Request for Cancellation of

Permanent License

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 - APPLICATION INFORMATION

Please cancel the following alcoholic beverage license:

Issued To:

License/Permit Number

Business Name

Licensee ID Number

I do

do not

wish to cancel retail tobacco permit number:

Is the permanent license accompanying this form?

Yes

SECTION 2 - AFFIDAVIT OF APPLICANT

NOTARIZATION REQUIRED

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-6007 - Division Of Alcoholic Beverages And Tobacco Request For Cancellation Of Permanent License