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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 4

SECTION 6 - AFFIDAVIT OF APPLICANT

FOR SPECIAL SALES LICENSE

NOTARIZATION REQUIRED

Name of Entity or Organization

"I, the undersigned individual, or if a corporation for itself, its officers and directors, hereby swear or affirm

that I am duly authorized to make the above and foregoing application for a special sales license which

authorizes the sale of alcoholic beverages for period of up to three (3) days. I understand this license does

not permit the sale of alcoholic beverages for consumption on the premises and only allows package sales

in sealed containers and agree that the location may be inspected and searched during the hours that the

special sale 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 beverages laws.

I swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791, 562.45, and

837.06, that the foregoing information is true to the best of my knowledge and that no other person or entity

except as indicated herein has an interest in the special sales license and that all of the above listed

persons or entities meet the qualifications necessary to hold this special sales license."

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 4