Dbpr Form Ab&t 4000a-038 - Application For Tax Exempt Wine Permit - Department Of Business And Professional Regulation - Florida

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DBPR Form AB&T
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
4000A-038
DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO
Rev. 12/03
1940 NORTH MONROE STREET • TALLAHASSEE FL 32399-1022
APPLICATION FOR TAX EXEMPT WINE PERMIT
Name of Applicant
Address of Applicant
Contact Person
Telephone
(
)
Fax No.
(
)
Check the applicable box:
Pastor
Religious Order
Religious Body
Monastery
Synagogoe
Priest
Church
Minister
Rabbi
The religious purpose for which the wine is to be used:
Estimated amount of wine in total gallons to be purchased annually:
Subscribed and sworn before me:
This
day of
, Year
Applicant's Signature
Notary Public
Type or Print Name and Title
FOR DIVISION USE ONLY
Date:
Permit No.
The wines ordered under this permit are to be used for religious or sacramentsl purposes only. This permit allows
continued purchases from any duly licensed wholesaler or retailer and is in effect until revoked by the Division of
Alcoholic Beverages and Tobacco.
Approved By:

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