Application For Transfer In Location Of Alcoholic Beverage Retailers Permit Form

Application For Transfer In Location Of Alcoholic Beverage Retailers Permit Form - 1996

(REVISED 4/96)

PERMIT DEPT USE ONLY

AMT. OF CHECK__________

CHECK NUMBER_________

PERMIT NUMBER_________

APPLICATION FOR TRANSFER IN LOCATION OF ALCOHOLIC BEVERAGE

RETAILERS PERMIT

I,_______________________________________________, doing business as

_______________________________________________________________,

ABC Permit No. _____________ and located at _________________________

(street)

________________________________________, hereby submit application for

(City)

(County)

a transfer in location to:_____________________________________________

(street)

(city)

Telephone Number

(business)______________(home)____________________

Does applicant have, or has the applicant ever had, an interest in any

other alcoholic beverage retailer’s permit?_______ If "yes" explain fully:

__________________________________________________________

II.

Is the applicant indebted to the State of Mississippi for any taxes, fees or

payment of penalities imposed by law or by any rule or regulation of the

Commission?_________ If "yes" explain fully: ______________________

__________________________________________________________

III.

List your Mississippi Sales Tax Number: __________________________

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 hereby. I

certify that the information presented on this application to be true and correct, to the

best of my knowledge and belief.

________________________________

Date__________________

________________________________

(title)

SWORN TO AND SUBSCRIBED before me, this the_____day of______________________,______.

___________________________________________

NOTARY PUBLIC

My commission expires:_____________________

Application For Transfer In Location Of Alcoholic Beverage Retailers Permit Form - 1996

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