Dbpr Form Abt-6013 - Examination Application (Page 2 of 3) in pdf

SECTION 3 – APPLICANT BACKGROUND INFORMATION

Applicant Name

1. Have you ever been arrested, issued a notice to appear, or had any criminal charges

Yes

filed against you within the past 15 years in any state of the United States or its

territories?

If yes, list date, location, and type of offense in the spaces below and provide a

Certified Copy of the Arrest Disposition.

If you are a convicted felon and have had your civil rights restored in Florida, attach a

Certified Copy.

____________________________________________________________________

___________________________________________________________________

2. Are you an official with State police powers granted by the Florida Legislature?

Yes

If yes, please provide the details:

_______________________________________________________________________

3. Do you currently have financial interest in any business selling alcoholic beverages?

Yes

If yes, list business name, location and license number:

_______________________________________________________________________

4. Are you employed full or part-time or receiving any remuneration from any vendor

Yes

licensed under the beverage laws of the State of Florida?

If yes, list business name, location, and details:

_______________________________________________________________________

5. Have you ever had any type of alcoholic beverage, salesman's, cigarette, or tobacco

Yes

permit refused, revoked or suspended anywhere?

If yes, list business name, location and date:

____________________________________________________________________

___________________________________________________________

Dbpr Form Abt-6013 - Examination Application Page 2