Form Dbpr Abt-6008 - Application For Importer Or Broker Sales Agent Page 5

SECTION 6 – DISCLOSURE OF INTERESTED PARTIES

Note: Failure to disclose an interest, direct or indirect, could result in denial, suspension and/or

revocation of your license.

Trade Name (D/B/A)

1. List below the name, title and address for all principals of the business. Attach extra sheets if necessary.

NAME

TITLE

ADDRESS

2. Have you in the past or presently, individually or as an officer or stockholder of a corporation in this state

or any other state:

a. Held stock or had any interest in, affiliated or connected with, directly or indirectly, any

Yes

business which sells any alcoholic beverages at retail?

b. Held stock or had any interest in, affiliated or connected with, directly or indirectly, any

Yes

business which manufactures, distributes, imports or exports any alcoholic

beverages?

If the answer to either of these questions is “yes”, list full particulars to include business names, cities, states,

and dates.

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Parent category: Legal