Application For Registered Retail Agent - Arizona Department Of Liquor Licenses And Control
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1
2DLLC USE ONLY
Arizona Department of Liquor Licenses and Control
800 W Washington 5th Floor
Date DLLC Approval:
Phoenix, AZ 85007-2934
Liquor License #:
(602) 542-5141
CSR:
Application for Registered Retail Agent
A.R.S. §4-222(A) – (C)
A service fee of $25.00 will be charged for all dishonored checks (A.R.S. § 44-6852)
CERTIFICATE OF REGISTRATION FOR A RETAIL AGENT IS VALID UNTIL CANCELED BY THE LICNESEE AND MAY NOT BE
TRANSFERRED. A FEE OF $50.00 WILL BE DUE WITH THIS APPLICATION.
FALSE OR INCOMPLETE ANSWERS COULD RESULT IN THE DENIAL OF CERTIFICATION
SECTION 1: Arizona Licensee Information Wishing to Register a Retail Agent
________________________________________________________________________
1.
Individual Owner/Agent's Name:
Last
First
Middle
2.
Business Name: ____________________________________________________________________________________________________
(Exactly as it appears on the exterior of premises)
3.
Business Location Address: _________________________________________________________________________________________
(Do not use PO Box)
Street
City
State
Zip
4.
Mailing Address: ___________________________________________________________________________________________________
(Where all correspondence will be mailed)
Street
City
State
Zip
_______________________________________
5.
Daytime Contact Phone:
6.
Your Arizona Liquor License Number: _______________________________
7.
Email Address: ____________________________________________________
8. Do you agree to notify the Department of Liquor of any proposed changes to information provided this application prior
to making any such changes?
Yes
No
9. Do you agree to keep all records, invoices, and other documents relating to the purchase, sale or delivery of spirituous
liquor for a period of two years and to keep those records easily accessible for examination?
Yes
No
SECTION 2: Proposed Retail Agent’s Information
________________________________________________________________________
1.
Registered Retail Agent's Name:
(Insert one name to appear on certification)
Last
First
Middle
2.
Business Name: ____________________________________________________________________________________________________
(Retail agent’s business, if different than licensee’s)
3.
Mailing Address: ___________________________________________________________________________________________________
(Do not use PO Box)
Street
City
State
Zip
4. Business Phone: ______________________________________ Daytime Contact Phone: _____________________________________
5.
Email Address: _____________________________________________________________________________________________________
I, ___________________________________________, hereby declare that I am the RETAIL AGENT representing the license in Section 1.
(Print full name of retail agent)
I acknowledge that
I have read this application, the contents and declare all statements are true, correct and complete.
handling of liquor contrary to
Arizona Revised Statutes will result in the immediate suspension of a Certification of Registration.
X _____________________________________________
(Signature of Applicant
Page 1 of 2
9/11/2015
Individuals requiring ADA accommodations please call (602)542-9027
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