Form Dbpr Abt-6001 - Examination Application For Alcoholic Beverage License And Tobacco Permit Page 4
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138.
Have you ever been arrested or issued a notice to appear in any state of the United States or its
territories?
Yes
No
If yes, provide the information requested below and a CERTIFIED COPY OF THE DISPOSITION.
Attach additional sheet if necessary.
Date
Location
Type of Offense
9.
Are you an official with State police powers granted by the Florida Legislature?
Yes
No
If yes, provide details:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_______________________________________________________________________________
NOTARIZATION STATEMENT
“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 I have fully disclosed any and all parties financially and or contractually
interested in this business and that the parties are disclosed in Section 12 of this application. I further swear
or affirm that the foregoing information is true and correct.”
STATE OF___________________
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
(ATTACH ADDITIONAL COPIES AS NECESSARY)
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