Record Of Delivery - Arizona Department Of Liquor Licenses And Control
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3Arizona Department of Liquor Licenses and Control
800 W. Washington, 5th Floor
Phoenix AZ 85007-2934
(602) 542-5141
Record of Delivery
Pursuant to A.R.S. § 4-203(J), a retail licensee permitted to deliver spirituous liquor shall make a record of delivery as required
by A.A.C. R19-1-504, at the time of delivery off the licensed premises on a form approved by the department. A
licensee may provide additional information regarding the delivery at his discretion.
1. Business Name:
(Exactly as it appears on the license)
2. Business Address:
Street
City
County
Zip Code
3. License Number:
4. Date of Delivery:
Time of Delivery:
AM / PM (circle one)
5. Address of Delivery:
Street
City
County
Zip Code
6. Type and Brand of Spirituous Liquor(s) Delivered:
7. The following information pertains to the person MAKING the delivery.
Name:
Signature:
(Please print)
8. The following information pertains to the person ACCEPTING the delivery.
THE LICENSEE SHALL REQUIRE THAT PROOF OF AGE BE SHOWN.
Name:
Date of Birth:
(Please print)
Identification Type:
ID Number:
(Serial Number)
Signature:
The Record of Delivery shall be retained by the Licensee for at least two (2) years as required by A.R.S. § 4-210(A)(7).
A LICENSEE THROUGH ANY EMPLOYEE MAKING DELIVERY SHALL BE LIABLE FOR ALL VIOLATIONS OF TITLE 4.
7/27/2015
Page 1 of 3
Individuals requiring ADA accommodations please call (602)542-9027
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