Form Ab-0023 - Application For License To Sell Alcoholic Beverages At Wholesale (Page 2 of 2) in pdf

11.

State the names and addresses of all persons related to you by blood, marriage or otherwise, who own, operate or have any kind of interest in

a Retail Store, Wholesale Distributor, Distillery or Supplier.

12.

Give the name and address of the owner of the premises on which the business is to be located and the amount of the rental, if any. Also

submit a copy of any lease agreement which may be entered into.

13.

Do you sub-lease, or allow anyone to occupy any of the space covered in this lease? _______ If so, state the name of the person and the kind

of business being operated.

14.

Do you agree to accept full responsibility for the actions of all persons having a direct or indirect interest in the business and/or by you in the

conduct of your business?

15.

Give name and address of any relative employed by the Tennessee Alcoholic Beverage Commission.

16.

If you are indebted to the State of Tennessee for any tax, state the tax and amount.

17.

Do you hold a public office, either appointive or elective, or are you a public employee, either National, State, City or County?

“YOUR STATEMENT IS MADE UNDER OATH OR AFFIRMATION. PROVIDING OR INCOMPLETE

WARNING:

INFORMATION ARE GROUNDS FOR REJECTION OF APPLICATION OR SUSPENSION OR

REVOCATION OF PERMIT IF ISSUED. FALSE STATEMENTS OR INCOMPLETE INFORMATION ARE

ALSO SUBJECT TO THE PENALTIES OF PERJURY UNDER TENNESSEE LAW”

All data, written statements, affidavits, evidence or their documents submitted in support hereof,

or upon bearing hereon, shall be deemed to be a part of this application.

The applicant or applicants agrees that the place for which application is made will be operated in conformity with Chapter 257,

Public Acts of 1963, and in conformity with all applicable rules and regulations made pursuant to law, which are now, or may hereafter be, in force.

* “THE ACCEPTANCE OF FEES DOES NOT GUARANTEE THE ISSUANCE OF A LICENSE OR PERMIT” *

Application authorized by

Print Name, Owner of Establishment

Print Name, Applicant

Signature, Owner of Establishment

Signature, Applicant

----------------------------------------------------------------------------------------------------------------------------- -------------------------------------

Subscribed and sworn to before me this

day of

My Commission Expires

Notary Public

Notary Seal

TABC Validation

The State of Tennessee and the Tennessee Alcoholic Beverage Commission are

Equal Opportunity Employers. Discrimination, in any of its practices, which is

based on age, race, sex, color, religion, national origin, disabling condition or any

other nonmerit factor is prohibited.

Thus, the Tennessee Alcoholic Beverage

Commission is an equal opportunity, equal access, affirmative action public entity.

FOR ADDITIONAL INFORMATION:

Contact the agency ADA Coordinator for this state agency:

Assistant

Director at 615-741-1602 or the Tennessee Office of Americans with Disabilities,

Department of Personnel. Alternate formats of this notice are available on request.

AB-0023 (Rev. 9-14)

RDA 2116

Form Ab-0023 - Application For License To Sell Alcoholic Beverages At Wholesale Page 2

Related Articles

Related forms

Related Categories