Form Lcb-89 - Participant Manual - Commonwealth Of Pennsylvania Page 33
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41PLCB-931 12/04
BUREAU OF
DECLARATION OF AGE
PENNSYLVANIA
STORE OPERATIONS
LIQUOR CONTROL BOARD
6
DATE
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I,
hereby represent to
A State Store or Licensee of the Pennsylvania Liquor Control Board that I am of full age and
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discretion and over the age of 21 years, having been born on
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in
This statement is made to induce said store or licensee above named to sell or otherwise furnish alcoholic beverages to the undersigned.
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Serial Number of Identi cation Card
I UNDERSTAND THAT I AM SUBJECT TO CRIMINAL PENALTIES INCLUDING FINES, IMPRISONMENT, AND/OR LOSS OF
DRIVING PRIVILEGES FOR ANY MISREPRESENTATION HEREIN.
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WITNESS:
SIGNATURE
(Person Requesting Service)
NAME
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ADDRESS
ADDRESS
The PLCB reserves the right to furnish the Declaration of Age card to any appropriate law enforcement agency.
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Identi cation Shown
Signature Compared
Yes
No
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Race
Sex
Complexion
Hair Color
Weight
Height
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Code Requested
Time
Reason Refused
Completing the Card
Ask the Individual to:
1. Print name
2. Enter birth date
3. Enter place of birth (City and State)
4. Sign the card
5. Enter home address
The Server/Licensee then should fill in the:
6. Current date
7. Name of establishment
8. Serial number of the ID card presented by the customer
9. Witness-licensee/server name and address
10. Type of ID shown
11. Signature compared-check YES or NO
12. If sale is refused, enter a physical description of the customer to include race, sex, complexion, hair color,
approximate weight, height, and distinguishing features.
13. Code requested-what they purchased to go
14. Reason refused
*FOR SPANISH VERSION, SEE REVERSE SIDE OF DECLARATION OF AGE CARD
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