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Form Dbpr Abt-6034 - Application For Bottle Club License And Retail Tobacco Products Dealer Permit Page 10

SECTION 12 - 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 I have fully disclosed any and all parties financially and or contractually

interested in this business and that the parties are disclosed in section 11 of this application. I further swear

or affirm that the foregoing information is true and correct.”

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-6034 - Application For Bottle Club License And Retail Tobacco Products Dealer Permit Page 10