Business Information / Name Change Request - Arizona Department Of Liquor Licenses And Control

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DLLC USE ONLY
Date:
Arizona Department of Liquor Licenses and Control
800 W Washington 5th Floor
Approved by:
Phoenix, AZ 85007-2934
(602) 542-5141
Business Information / Name Change Request
(No Fees Required)
1
License Number: ___________________________________________
.
2.
Individual / Agent Name:___________________________________________________________________________________
Last
First
Middle
3.
Current Business Name: _____________________________________________________________________________________
(Exactly as it appears on the license)
For all changes that apply to you, please check applicable boxes and complete:
New Business Name: _______________________________________________________________________________________
NOTE
New Business Location Address:
:
THIS IS NOT A LOCATION TRANSFER, THIS IS A LOCAL GOVERNMENT
OR U.S. POSTAL AUTHORIZED ADDRESS CHANGE, DOCUMENTATION MUST BE ATTACHED.
___________________________________________________________________________________________________________
Street
City
State
Zip

New Business Phone: _________________________
Daytime Contact Number: ___________________________
New Mailing Address: ______________________________________________________________________________________
Street
City
State
Zip
Other (please explain): _____________________________________________________________________________________
(Attach additional sheet in necessary)
NOTARY

I,
, hereby declare that an AUTHORIZED PERSON filing this request.

(Pr
int F
ull
Name)
I have read this document and the contents and all statements are true, correct and complete.
Signature: ______________________________________________
State of _______________County of ______________________
The foregoing instrument was acknowledged before me this ____________ day of ______________________, ____________
Day
Month
Year
My commission expires on ____________________
________________________________________________________
Day/ Month/Year
Signature of NOTARY PUBLIC
4/7//16
Page 1 of 1
Individuals requiring ADA accommodations please call (602)542-9027

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