Co-Op Deactivation - Arizona Department Of Liquor Licenses And Control
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1Arizona Department of Liquor Licenses and
FOR DLLC USE ONLY
Control
Co-op #:
800 W Washington 5th Floor
Deactivation Date:
Phoenix, AZ 85007-2934
CSR:
(602) 542-5141
CO-OP DEACTIVATION
License Number: _________________________________________ Co-op Number: _____________________________________________
Controlling Person / Agent Name: ______________________________________________________________________________________
Corporation Name: ____________________________________________________________________________________________________
Business Name: ________________________________________________________________________________________________________
Business Address: ______________________________________________________________________________________________________
Mailing Address: _______________________________________________________________________________________________________
Email Address: _________________________________________________________________________________________________________
Business Phone: ___________________________________ Daytime Contact Phone Number: ___________________________________
REASON FOR DEACTIVATION
Use Back of Page if Necessary
NOTARY
I,
______________________________________________ hereby declare that I am the CONTROLLING PERSON and / or
(Print Full Name)
AGENT filing this notification. I have read this document and the contents and all statements are true, correct and complete.
X __________________________________________________
State of _________________ County of _______________________
The foregoing instrument was acknowledged before me this
My Commission Expires on: ____________________
___________ Day of _________________________, _____________
Date
Day
Month
Year
_________________________________________________________
Signature of Notary
2/19/2016
Individuals requiring ADA accommodations please call (602)542-9027
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Parent category: Legal