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Form Dbpr Abt-6034 - Application For Bottle Club License And Retail Tobacco Products Dealer Permit Page 13

SECTION 15 - DEPARTMENT OF REVENUE CLEARANCE

COMPLETE THIS SECTION IF APPLYING FOR A TRANSFER OF OWNERSHIP

Trade Name (D/B/A)

The following information is extremely important and should be read in its entirety. Because of restrictions placed on the Department of

Revenue in divulging confidential tax information, the business activity of the previous owner cannot be discussed without expressed

written consent. Therefore, if this application is for the transfer of an alcoholic beverage license, the following section of this form must

be completed before the Department of Revenue can approve your application. If the owner is unwilling to complete this disclosure

form, you may request a meeting with a Department of Revenue representative and the owner jointly to discuss any potential liability for

which you could be held responsible.

DO NOT RETURN THIS FORM TO AB&T WITH YOUR APPLICATION

SALES TAX

NOTARIZATION REQUIRED

This section must be completed by the present owner of the alcoholic beverage license and must

accompany your application for sales tax registration.

Purchaser’s Name

Business Name

Sales Tax Number

Location Address

City

State

Zip Code

__________________________________________________________________________

Signature of Owner, Partner or Principal Corporate Officer

“I, the undersigned individually, or if a corporation, on its behalf and its officers, hereby authorize the

Department of Revenue to release to the above purchaser, the Division of Alcoholic Beverages and Tobacco

and ______________________________________________ the status of my account

number__________________________________.

Seller’s Name_____________________________________________________________________

STATE OF___________________

_________________________________________________

Signature of Owner, Partner, or Principal Corporate Officer

COUNTY OF_________________

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.

Notary Public Stamp:

Commission Expires: ______________

Form Dbpr Abt-6034 - Application For Bottle Club License And Retail Tobacco Products Dealer Permit Page 13