Form Ab-0183 - Delivery Service License Application (Page 3 of 3) in pdf

20. Please list (on a separate sheet and made a part hereto this application) motor vehicle (mv)

information of motor vehicles used in the delivery service’s business, including (a) address

where said mv is principally garaged, (b)mv identification number, (c) state and county of mv

registration, (d) mv tag number and state, (e) mv make, (f) mv model, (g) proof of liability

insurance and if owned or leased by an employee (a) employee name, (b) employment

capacity and (c) employee address. This list is subject to applicant supplementation with

changes made in motor vehicles used in the delivery service’s business.

WARNING: “YOUR STATEMENT IS MADE UNDER OATH OR AFFIRMATION. PROVIDING

FALSE OR INCOMPLETE 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 premises and activities 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 20_____

My Commission Expires_________________________

_____________________________________

Notary Public

Notary Seal

TABC USE ONLY

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-0183

RDA 2116

Form Ab-0183 - Delivery Service License Application Page 3

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