Form Ab&t 4000a-005ez - Election Of Surcharge Calculation Method And Inventory Report
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1DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
DBPR Form AB&T
DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO
4000A-005EZ
1940 North Monroe Street, Tallahassee, Florida 32399-1022
Revised 11/98
ELECTION OF SURCHARGE CALCULATION METHOD AND INVENTORY REPORT
This application is for a:
NEW LICENSE
TRANSFER OF A LICENSE
CHANGE OF METHOD
NONPROFIT ORGANIZATION PERMIT
I hereby elect to pay future surcharges based on the:
PURCHASES METHOD
SALES METHOD
Applicant's Name:
Alcoholic Beverage License Number:
License Name:
Mailing Address:
Series:
City:
, FL
Zip:
Location Address:
City:
, FL
County:
Zip:
Contact Person:
Telephone: Bus.
Home
Title
Date
Applicant's Signature
FOR LICENSE TRANSFERS
Former
Applicant Name:
License Number:
Business Name:
License Series:
Former owner certifies that the
New owner and former owner certify that the following
inventory is being transferred for consumption on premises:
Purchases Method
Gallons of Draft Beer
Sales Method
Gallons of Packaged Beer
was used to calculate the beverage surcharge and
Gallons of Coolers
that all surcharges have been paid as of
Gallons of Cider
.
Gallons of Wine
Gallons of Liquor
Signature of Former Owner
Date
Signature of New Owner/Applicant
Date
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