Form Dbpr Abt-6004 - Examination Application Of Officer/stockholder
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9DBPR ABT-6004 – Division of Alcoholic Beverages and Tobacco Change of Officer/Stockholder
Application
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL
REGULATION
1940 North Monroe Street
Tallahassee, FL 32399-0783
NOTE – This form must be submitted as part of an
application packet
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation or your local district office. Please submit your
completed application to your local district office. This application may be submitted by mail, through
appointment, or it can be dropped off. A District Office Address and Contact Information Sheet can be
found on AB&T’s page of the DBPR web site at the link provided below.
SECTION 1 - CHECK TRANSACTION REQUESTED
Transaction Type:
Change of Officer/Stockholder
Amendment to Corporate/Entity Name
SECTION 2 – LICENSE INFORMATION
Corporate Document Number
Full Name of Applicant
List all current license numbers for the entity listed above (Attach additional sheet if necessary)
License Number
License Number
Current Trade Name (D/B/A)
FEIN # or Social Security Number*
Do you wish to change the current Trade Name (D/B/A)?
Yes
No
If yes, please list the new Trade Name (D/B/A) below:
Mailing Address
City
County
State
Zip Code
Resident Agent/ Contact Person
Phone Number
Street Address
City
State
Zip Code
Is the change of officer application due to revocation proceedings?
Yes
No
If yes, is there any personal relationship to any of the former officers?
Yes
No
If yes, explain the relationship:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
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