Amendment Application For A Change Of Beneficial Interest Or Transfer/issuance Of Stock - Massachusetts Alcoholic Beverages Control Commission Page 3

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The Commonwealth of Massachusetts
Alcoholic Beverages Control Commission
239 Causeway Street
Boston, MA 02114
AMENDMENT APPLICATION FOR A CHANGE OF BENEFICIAL INTEREST OR
TRANSFER/ISSUANCE OF STOCK
Please complete this entire application, leaving no fields blank. If field does not apply to your situation, please write N/A.
1. NAME OF LICENSEE
(Business Contact)
ABCC License Number
City/Town of Licensee
2. APPLICATION CONTACT
The application contact is required and is the person who will be contacted with any questions regarding this application.
First Name:
Middle:
Last Name:
Title:
Primary Phone:
Email:
3. BUSINESS CONTACT
Please complete this section ONLY if there are changes to the Licensee phone number, business address (corporate
headquarters), or mailing address.
Entity Name:
Primary Phone:
Fax Number:
Alternative Phone:
Email:
Business Address (Corporate Headquarters)
Street Number:
Street Name:
City/Town:
State:
Zip Code:
Country:
Mailing Address
Check here if your Mailing Address is the same as your Business Address
Street Number:
Street Name:
City/Town:
State:
Zip Code:
Country:
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