File Deactivation Form - Arizona Department Of Liquor Licenses And Control
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1DLLC USE ONLY
Arizona Department of Liquor Licenses and Control
800 W Washington 5th Floor
Date:
Phoenix, AZ 85007-2934
Processed by:
(602) 542-5141
FILE DEACTIVATION FORM
Print and use black ink only
1.
TYPE OF ACTION:
LICENSE SURRENDER
APPLICATION WITHDRAWAL
2.
LICENSE DATA:
LICENSE NUMBER: _____________________________________
CONTROLLING PERSON / AGENT NAME: ______________________________________________________________________________
BUSINESS LOCATION NAME: _________________________________________________________________________________________
BUSINESS LOCATION ADDRESS: ______________________________________________________________________________________
MAILING ADDRESS: _________________________________________________________________________________________________
REASON FOR WITHDRAWAL/SURRENDER
________________________________________________________________________________________________________
________________________________________________________________________________________________________
USE BACK OF PAGE IF NECESSARY
I,
, hereby declare that I am a 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 (Signature) ______________________________________________
State of ____________________County of ____________________
Controlling Person / Agent
The foregoing instrument was acknowledged before me this
My commission expires on: _______________________
____________ of ______________________ ____________
Day
Month
Year
__________________________________________________
FOR DLLC USE ONLY
Signature NOTARY PUBLIC
INVESTIGATIVE REVIEW
Requires Director or Designate and Chief of Investigations
DEPARTMENT PROTEST
or Designate approvals
DIRECTOR APPROVAL
YES
NO _________________________________________
CHIEF OF INVESTIGATIONS APPROVAL
YES
NO _________________________________________
REVIEW
EMPLOYEE
DATE
Received by
__________________________________
__________________
Background Investigator
__________________________________
__________________
(pending app.’s only)
Licensing Supervisor
__________________________________
__________________
Customer Service Rep.
__________________________________
__________________
Liquor Board
__________________________________
__________________
(Hearing files only)
DISPOSITIONS
Letter Attached ___________________
Intent to Halt
Revoked-Order#___________________
Application Denied
#____________________
Reverted-Order# __________________
Application Withdrawn
Page 1 of 1
9/11/2015
Individuals requiring ADA accommodations please call (602)542-9027
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