Dbpr Form Abt-6013 - Examination Application
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3DBPR ABT-6013 – Division of Alcoholic Beverages and Tobacco Application for Distributor’s
Salesperson of Wine or Spirits
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 at (850) 488-8288. Please send your completed
application and required fee(s) to:
Department of Business and Professional Regulation
1940 North Monroe Street
Tallahassee, FL 32399-1021
SECTION 1 – APPLICANT INFORMATION
Full Name of Applicant
Social Security Number*
Date of Birth
Race
Sex
Height
Weight
Eye Color
Hair Color
Current Residence Address
City
State
Zip Code
SECTION 2 – EMPLOYER INFORMATION
Employer’s Business Name
Employer’s Beverage License Number
Starting Employment Date with Distributor
Employer’s Location Address
City
State
Zip Code
*Social Security Number
Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless a Federal
statute specifically requires it or allows states to collect the number. In this instance, disclosure of social
security numbers is mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and
sections 409.2577, 409.2598, and 559.79, Florida Statutes. Social Security numbers are used to allow
efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance
with child support obligations. Social Security numbers must also be recorded on all professional and
occupational license applications and are used for licensee identification pursuant to the Personal
Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193,
Sec. 317. The State of Florida is authorized to collect the social security number of licensees pursuant to
the Social Security Act, 42 U.S.C. 405(c)(2)(C)(I). This information is used to identify licensees for tax
administration purposes.
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