Dbpr Form Ab&t 4000a-241 - Annual Schedule Of Vending Machine Locations - Department Of Business And Professional Regulation - Florida

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DBPR Form AB&T
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
4000A-241
DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO
Rev. 12/03
1940 NORTH MONROE STREET • TALLAHASSEE FL 32399-1022
ANNUAL SCHEDULE OF VENDING MACHINE LOCATIONS
(
)
Permit Name
Phone No.
Permit No.
Address
City
State
Zip
Month Reported
Yr
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
Vending Machine
Name and Address of
County
Serial Number
Vending Machine Location
Name

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