Form B-0188 - Application For Permit To Sell Alcoholic Beverages (Page 3 of 3) in pdf

Form B-0188 - Application For Permit To Sell Alcoholic Beverages Page 3

23. Does applicant acknowledge that it is prohibited from receiving any remuneration, by whatever name, within or outside

Tennessee affecting the profitability of wine sales in Tennessee? _____________________________________________

All data, written statements, affidavits, evidence or other documents submitted in support hereof,

or upon bearing heron, shall be deemed to be a part of this application.

The applicant or applicants agrees that the place 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.

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

FALSE OR INCOMPLETE INFORMATION IS 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”

*THE ACCEPTANCE OF FEES DOES NOT GUARANTEE THE ISSUANCE OF A LICENSE OR PERMIT*

Application Authorized By__________________________________________________________

Print Name, Applicant

________________________________________

Signature, Applicant

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Subscribed and sworn to before me on this ________________ day of _________________, 20_______.

My commission expires ________________________ ________________________________________

Notary Public

Notary Seal

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 non-merit 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 upon request.

AB-0188

RDA 2261

Form B-0188 - Application For Permit To Sell Alcoholic Beverages Page 3

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