Inactive / Active Status Form - 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:
Phoenix, AZ 85007-2934
Processed by:
(602) 542-5141
Activation Fees Collected:
INACTIVE / ACTIVE STATUS FORM
Pursuant to ARS Section 4-203 (G)
Print and use black ink only
Please check one box only:
INACTIVE STATUS
(Complete Questions 1, 2, 3, 4, 5, 6, 8)
ACTIVATING STATUS
(Complete Questions 1, 2, 3, 4, 5, 7, 8)
1.
License Number: _________________________________________
2.
Individual Owner / Agent Name: _______________________________________________________________________________
Last
First
Middle
3.
Business Name: ________________________________________________________________________________________________
4.
Business Location Address: _____________________________________________________________________________________
Street
City
State
Zip Code
5.
Date license was last used: ________________________ Date license went on inactive status: ________________________
6.
License is not being used because: _____________________________________________________________________________
_______________________________________________________________________________________________________________
7.
Future plans to place the license in use: _________________________________________________________________________
_______________________________________________________________________________________________________________
8.
Date you intend to place the license back in use: _______________________________________________________________
FALSE OR INCOMPLETE ANSWERS COULD RESULT IN CRIMINAL PROSECUTION AND THE DENIAL,
OR SUBSEQUENT REVOCATION OF A LICENSE OR PERMIT.
I,
, hereby declare that I am a CONTROLLING PERSON
(Print Full Name)
and /or AGENT filing this notification. I have read this document and the contents and all statements are true, correct
and complete.
X
(Signature)
State of ________________County of _________________
The foregoing instrument was acknowledged before me this
My commission expires on:
__________________
____________ of ______________________ _____________
Day
Month
Year
___________________________________________________
Signature of NOTARY PUBLIC
Page 1 of 2
9/11/2015
Individuals requiring ADA accommodations please call (602)542-9027
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