New Alcoholic Beverage Retailers Permit Application Page 9
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137.
Have you filed and paid your Mississippi State Income Taxes and your
Federal Income Taxes? _________________ If "no", explain fully:
__________________________________________________________
__________________________________________________________
8.
Have you ever been convicted of any of the following:
a. A felony in any state, federal or military court? __________________
b. A violation of the Local Option ABC Laws, Rules and Regulations, or
the Prohibition Laws in any state or local jurisdiction? _____________
c. A violation of any law relating to alcoholic beverages or beer such as
DUI, DWI, or public drunk in any state or local jurisdiction? ________
d. A violation of any drug related law? ______________
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PERSONAL RECORD SUPPLEMENT
(IF "YES" TO A, B, C OR D ABOVE, EXPLAIN FULLY)
List convictions (specific charges) ______________________________
__________________________________________________________
Date and jurisdiction of same __________________________________
__________________________________________________________
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____________________________________
APPLICANT’S SIGNATURE
__________________________
DATE
NOTARY
STATE OF ______________________
COUNTY OF _____________________
THIS DAY personally came and appeared before me, the undersigned authority in
and for the aforesaid jurisdiction, the within named ________________________________
who, after being by me first duly sworn, states on oath that the matters contained and set
forth in the foregoing application are true and correct as stated therein.
SWORN TO AND SUBSCRIBED before me, this the _______ day of ___________ , _______ .
_____________________________________________
NOTARY PUBLIC
My commission expires: ________________________________
ABCD 2007 (11/95)
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