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Dbpr Form Abt-6003 - Division Of Alcoholic Beverages And Tobacco Application For One/two/three Day Permits Or Special Sales License Page 3

SECTION 5 - AFFIDAVIT OF APPLICANT

FOR NON-PROFIT CIVIC ORGANIZATION ALCOHOLIC BEVERAGE PERMIT

NOTARIZATION REQUIRED

Name of Entity or Organization

"This is to certify that the applicant requesting the permit in the above and foregoing application is a non-

profit civic organization and that the permit, if used, will be used only by the organization making application,

on the date(s) requested and at the location stated. This is to further certify that the applicant organization

has not received more than three (3) permits within the calendar year and agree that the location may be

inspected and searched during the time that the permit is issued and business is being conducted without a

search warrant by authorized agents or employees of the Division of Alcoholic Beverages and Tobacco, the

Sheriff, his Deputies, and Police Officers for purposes of determining compliance with the alcoholic

beverage laws.

I, the undersigned individual, hereby swear or affirm that I am duly authorized to make the above and

foregoing statements on behalf of the applicant organization. Furthermore, I swear under oath or affirmation

under penalty of perjury as provided for in Sections 559.791, 562.45, and 837.06, Florida Statutes, that the

foregoing information is true to the best of my knowledge."

STATE OF___________________

_________________________________________________

APPLICANT SIGNATURE

COUNTY OF_________________

_________________________________________________

APPLICANT SIGNATURE

The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this ______Day

of______________, 20_____, By:____________________________________________

who is ( ) personally known to me OR ( ) who produced _________________________as identification.

________________________________________________ Commission Expires: ___________________

Notary Public

Dbpr Form Abt-6003 - Division Of Alcoholic Beverages And Tobacco Application For One/two/three Day Permits Or Special Sales License Page 3