Form Dbpr Abt-6004 - Examination Application Of Officer/stockholder (Page 7 of 9) in pdf

Form Dbpr Abt-6004 - Examination Application Of Officer/stockholder Page 7

SECTION 8 - AFFIDAVIT OF APPLICANT

NOTARIZATION REQUIRED

Trade Name (D/B/A)

“I, the undersigned individually, 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 and, as such, I hereby swear or affirm

that the attached sketch or blueprint is substantially a true and correct representation of the premises to be

licensed and agree that the place of business, if licensed, may be inspected and searched during business

hours or at any time business is being conducted on the premises without a search warrant by officers of the

Division of Alcoholic Beverages and Tobacco, the Sheriff, his Deputies, and Police Officers for the purposes

of determining compliance with the beverage and retail tobacco laws.”

“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 and that no other person or entity except as

indicated herein has an interest in the alcoholic beverage license and/or tobacco permit, and all of the above

listed persons or entities meet the qualifications necessary to hold an interest in the alcoholic beverage

license and/or tobacco permit.”

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

Form Dbpr Abt-6004 - Examination Application Of Officer/stockholder Page 7