New Alcoholic Beverage Retailers Permit Application Page 6
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13VI.
Will this business be operated as an on-premises retailer club as
defined by S. 67-1-5 (n) of the 1972 MCA ? __________ If "yes", list the
officers and directors of the club below.
NAME
TITLE
_____________________________
________________________________
_____________________________
________________________________
_____________________________
________________________________
_____________________________
________________________________
_____________________________
________________________________
Note: Each person listed above must submit a PERSONAL RECORD (Form 1001) and
two properly executed fingerprint cards with a certified check for $24.00 may payable to
ABC FF with this application.
PERMITTEE CERTIFICATION AND OATH
I, _______________________________ , certify under penalty of perjury that
the organization applying for this Alcoholic Beverage Retailers Permit does meet
the qualifications of a permittee as described in Sections 67-1-5, 67-1-51, 67-1-
55 and 67-1-69 of the Mississippi Code of 1972, Annotated. I affirm that this
organization will comply fully with the provisions of the Local Option Alcoholic
Beverage Control Laws, Rules and Regulations in the purchase, sale, and
handling of alcoholic beverages and will keep all records and make all reports
and remittances as required thereby. I certify that the information presented on
this application to be true and correct, to the best of my knowledge and belief.
________________________________
Date _______________________
________________________________
(title)
SWORN TO AND SUBSCRIBED before me, this the _____ day of _____________, _______.
______________________________
NOTARY PUBLIC
My commission expires: ________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial