Application For Registration Of A Retail Co-Op Agent - Arizona Department Of Liquor Licenses And Control

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FOR DLLC USE ONLY
Co-op #:
Arizona Department of Liquor Licenses and Control
800 W Washington 5th Floor
Approval Date:
Phoenix, AZ 85007-2934
Expiration Date:
(602) 542-5141
CSR:
APPLICATION FOR REGISTRATION OF A RETAIL
CO-OP AGENT
A non-refundable fee of $5.00 per member will apply.
A service fee of $25.00 will be charged for all dishonored checks (A.R.S. 44-6852)
1. License #:
2. Agent’s Name:
Last
First
Middle
3. Corporation Name:
4. Business Name:
5. Business Address:
City
State
Zip
6. Mailing Address:
(All correspondence will be mailed to this address)
City
State
Zip
7. Email Address:
8. Business Phone:
Daytime Contact Number:
9. Date of Birth:
Place of Birth:
Height: ______________________
Weight: _____________________
Eye Color: ___________________
Hair Color: ___________________
10. I hereby certify that if approved to operate as a registered retail agent, that I will comply with all laws and rules, promulgated to
control cooperative purchases.
NOTARY
I,
_______________________________________________________ Hereby declare that I am the APPLICANT filing this
(Print Full Name)
agreement. I have read the agreement and all statements are true, correct and complete
X ____________________________________________
State of _________________ County of _______________________
The foregoing instrument was acknowledged before me this
(Signature of APPLICANT)
__________ Day of _____________________, ___________
Day
Month
Year
My Commission Expires on: ____________________
___________________________________________________
Date
Signature of Notary
1/1/2016
Individuals requiring ADA accommodations please call (602)542-9027

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