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

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SECTION I -- STATEMENT OF OWNERSHIP
ALCOHOLIC BEVERAGE RETAILER PERMIT APPLICATION.
I.
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)

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