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Dbpr Form Ab&t 4000a-240 - Monthly Changes Of Vending Machine Locations - Department Of Business And Professional Regulation - Florida

DBPR Form AB&T

DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION

4000A-240

DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO

Rev. 12/03

1940 NORTH MONROE STREET • TALLAHASSEE FL 32399-1022

MONTHLY CHANGES OF VENDING MACHINE LOCATIONS

Phone No.

(

)

Permit Name

Permit No.

Address

City

State

Zip

Month Reported

Reporting Period

through

This report is true and correct to the best of my knowledge and belief and is submitted under penalty of perjury.

Typed or Printed Name

Authorized Signature

In compliance with Chapter 210, Florida Statutes, all changes of vending machine locationsmust be reported monthly. If no changes took

place during a month, then a statement to this effect should be noted on page one of the monthly cigrette report.

NOTE:

New placements of vending machines should be listed first and so indicated.

Vending machines removed from locations should follow properly indicated and must include the number of packages of

cigarettes "returned to stock"

Vending Machine

Name and Address of

Return

Serial Number

Vending Machine Location

County Name

to Stock

Dbpr Form Ab&t 4000a-240 - Monthly Changes Of Vending Machine Locations - Department Of Business And Professional Regulation - Florida