Affidavit And Application For Class I Temporary Permit Form (Page 2 of 2) in pdf

Affidavit And Application For Class I Temporary Permit Form Page 2

PERMITTEE CERTIFICATION AND OATH

I, _________________________________________ , certify under penalty

of perjury that the organization applying for this Temporary Class I Permit is a

bona fide nonprofit civic or charitable organization and, as such, does meet the

qualifications of Section 67-1-11, 67-1-37, 67-1-51 (2) and (3), 67-1-55, 67-1-57

(excluding paragraph (e)) 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 is true and correct, to the best of my knowledge and belief.

BY: ________________________________________

TITLE: ______________________________________

DATE: _______________________________________

NOTARY

State of Mississippi

County of ______________________

THIS DAY, personally came and appeared before me, the undersigned

authority in and for the county and state aforesaid, the within named

__________________________ , who, after being by me first duly sworn, states

on oath that the matters and things contained and set forth in the foregoing

application are true and correct.

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

____________________________________

Notary Public

My commission expires: _____________________

Affidavit And Application For Class I Temporary Permit Form Page 2