Application For Transfer In Officers/stock Of Alcoholic Beverage Retailers Permit

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REVISED
PERMIT DEPT USE ONLY
(5/96)
AMT OF CHECK________
CHECK NUMBER_______
PERMIT NUMBER______
APPLICATION FOR TRANSFER IN OFFICERS/STOCK OF ALCOHOLIC
BEVERAGE RETAILERS PERMIT
I,__________________________________________,hereby submit application
(corporate officer’s name president/vice president)
for a transfer in officers of: __________________________________________
(corporate name)
_____________________________________________________________________________________________.
(doing business as)
Telephone Number
(business)______________________ (home)_________________________________
II.
Does the applicant have, or has the applicant ever had, an interest in any
other alcoholic beverage retailer’s permit?________ If "yes", explain fully:
__________________________________________________________
__________________________________________________________
III.
Is the applicant indebted to the State of Mississippi for any taxes, fees or
payment of penalties imposed by law or by any rule or regulation of the
Commission?_________________ If "yes", explain fully:______________
__________________________________________________________
IV.
List your Mississippi Sales Tax Number:___________________________
STATEMENT OF OWNERSHIP
ALCOHOLIC BEVERAGE RETAILER PERMIT APPLICATION
I.
List the amount of stock ,__________common and preferred, _________
and each officer, director, and majority stockholder below. Include a copy
of the corporate minutes showing this change along with a copy of the
stocks sold.
NAME
CORP. TITLE
ADDRESS
SHARES OWNED
____________________ _______________
__________________
_______________
__________________
____________________ _______________
__________________
_______________
__________________
____________________ _______________
__________________
_______________
__________________
____________________ _______________
__________________
_______________
__________________
(Note: Each officer*, director and the majority stockholder must submit a PERSONAL RECORD
(Form 1001), a SUMMARY FINANCIAL STATEMENT (Form 2007); and two (2) properly executed
fingerprint cards with a certified check for $24.00 made payable to ABC FF with this application.
A separate SUMMARY FINANCIAL STATEMENT must be completed for the corporation.

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