Form Abl 902c - Abl 902 Checklist Page 5
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Number:
FEI/SSN
Name of Sole Proprietorship, Corporation, Partnership, LLC, etc.
Name
Home Address
City
State
Zip
Yr/Mo/Date of SC Residency
Date of Birth
Social Security No.
Federal Employer Identification No.
Principal/Type: (use above #1-12)
Percent of ownership
Have you as an individual, or as an organization in which you were a principal, had revoked or suspended in this state or any other
state any license to sell beer, wine, or alcoholic liquors?
Yes
No
If yes, attach explanation.
Have you been convicted of a crime in South Carolina or any other state?
Yes
No
If yes, attach explanation.
This Consent and Waiver shall be effective as of the date
SWORN to and subscribed before me this
set forth on the attached pages until revoked in writing by
day of
, year of
the ABL-946R completed by the applicant or a principal
Notary Public for
signing this Consent and Waiver, or until the applicable
permit or license is terminated or revoked.
My Commission Expires:
Notary (L.S.)
Notary (printed name)
Taxpayer's Signature
Name
Home Address
City
State
Zip
Yr/Mo/Date of SC Residency
Date of Birth
Social Security No.
Federal Employer Identification No.
Principal/Type: (use above #1-12)
Percent of ownership
Have you as an individual, or as an organization in which you were a principal, had revoked or suspended in this state or any other
state any license to sell beer, wine, or alcoholic liquors?
Yes
No
If yes, attach explanation.
Have you been convicted of a crime in South Carolina or any other state?
Yes
No
If yes, attach explanation.
This Consent and Waiver shall be effective as of the date
SWORN to and subscribed before me this
set forth on the attached pages until revoked in writing by
day of
, year of
the ABL-946R completed by the applicant or a principal
Notary Public for
signing this Consent and Waiver, or until the applicable
permit or license is terminated or revoked.
My Commission Expires:
Notary (L.S.)
Notary (printed name)
Taxpayer's Signature
IF MORE THAN TWO PRINCIPALS, PLEASE SUBMIT AN ADDITIONAL ABL-946
44221024
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