Form Dbpr Abt-6005 - Application For Tobacco Products Wholesale Dealer (Page 7 of 7) in pdf

Form Dbpr Abt-6005 - Application For Tobacco Products Wholesale Dealer Page 7

SECTION 6 - AFFIDAVIT OF APPLICANT

NOTARIZATION REQUIRED

Trade Name (D/B/A)

“I hereby swear or affirm under penalty of perjury that the facts set forth in the forgoing application are in all

respects true and correct. I further agree this place of business may be inspected and searched during business

hours or at any time business is being conducted on the premises, 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 the purposes of determining compliance with the cigarette 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 tobacco permit, and all of the above listed persons or entities meet the

qualifications necessary to hold an interest in the 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

DIVISION USE ONLY

ID Number

Form Dbpr Abt-6005 - Application For Tobacco Products Wholesale Dealer Page 7