Affidavit And Application, Class Ii Temporary Permit Form (Page 2 of 2) in pdf

Affidavit And Application, Class Ii Temporary Permit Form Page 2

PERMITTEE CERTIFICATION AND OATH

I, ______________________________________, certify under penalty of

perjury that the organization applying for this Temporary Class II Permit does

meet the qualifications of Sections 67-1-51(l), (m), (n), (o), (p) or (q), 67-1-37, 67-

1-51 (2) and (3), 67-1-55, 67-1-57 and 67-1-59. I affirm that this organization, in

the exercise of this permit, will comply with the Local Option Alcoholic Beverage

Control Laws, Rules and Regulations, relative to 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

the application to be true and correct, to the best of my knowledge and belief.

BY: _________________________________

TITLE: _______________________________

DATE: _______________________

NOTARY

State of __________________

County of _________________

THIS DAY personally appeared before me, the undersigned authority in

and for the county and state aforesaid, the within named __________________

with, after being duly sworn states on oath that the matters and things contained

and set forth in the foregoing application are true and correct as stated.

Sworn to and subscribed before me, this the ___ day of ___________, 19___.

_______________________________

Notary Public

My commission expires: ____________________

Affidavit And Application, Class Ii Temporary Permit Form Page 2