Waiver Of Operation Application Form - Alaska Alcoholic Beverage Control Board
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1Alcoholic Beverage Control Board
Waiver of Operation
th
550 W. 7
Avenue, Suite 540
Application
Anchorage, Alaska 99501
(907) 269-0350 FAX (907) 272-9412
AS 04.11.330(a)(3)
15 AAC 104.170
License Information
FEES*
Liquor License Number
License Type
Waiver Fee
$
Penalty
$ 1,000.00
(If applicable)
Local Governing Body
(City, Borough or Unorganized)
Total Submitted
$
Licensee(s)’s Name & Mailing Address
*
The fee is non-refundable [15 AAC 104.170(c)]
Contact or Message Telephone Number:
Doing Business As (Business Name)
Street Address or Location of Business
City
Waiver Request Information
This waiver application is the
¨ 1
st
Request ¨ 2
nd
Request ¨ 3
rd
Request ¨ Other _______
Waiver Request for Calendar Year
Is this license for sale?
¨ Yes
¨ No
Explanation of the circumstances for non-operation of license. Include relevant information as to why the license was not
operated, any future plans for operating the license and projected timelines.
Attach additional sheets if necessary.
Signature of Licensee(s)
Signature
Signature
Name (Please Print)
Name (Please Print)
Date
Date
WaiverApp 6/00
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