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Form 1001 - Statement Of Ownership Alcoholic Beverage Retailer Permit Application Form

SECTION I -- STATEMENT OF OWNERSHIP

ALCOHOLIC BEVERAGE RETAILER PERMIT APPLICATION.

Name of business__________________________Permit No.__________

II.

Will this business be operated as an on premises retailer club as defined

by S. 67-1-5(n) of the 1972 MCA?_________ If "yes", list the officers and

directors of the club below.

NAME

TITLE

_____________________________

________________________________

_____________________________

________________________________

_____________________________

________________________________

_____________________________

________________________________

_____________________________

________________________________

NOTE: Each person listed above must submit a PERSONAL RECORD (Form 1001) and

two (2) FINGERPRINT CARDS with a certified check or money order for $24.00

made payable to ABC-FF with this application.

PERMITTEE CERTIFICATION AND OATH

I,________________________________________, certify under penalty

of perjury that the organization applying for this Alcoholic Beverage

Retailers Permit does meet the qualifications of a permittee as described

in Sections 67-1-5, 67-1-51, 67-1-55, and 67-1-69 of the Mississippi Code

of 1972, Annotated. I affirm that this organization will comply fully

with the

provisions of the Local Option Alcoholic Beverage Control Laws,

Rules

and Regulations in the purchase, sale, and handling of alcoholic

beverages and will keep all records and make all reports and

remittances

as required thereby. I certify that the information presented

on this

application to be true and correct, to the best of my

knowledge and belief.

__________________________

SIGNATURE

________________________________

TITLE

SWORN TO AND SUBSCRIBED before me, this the______day of___________19___.

________________________________

notary public

My commission expires:_________________________

Form 1001 (11/95)

Form 1001 - Statement Of Ownership Alcoholic Beverage Retailer Permit Application Form

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