Request For Notice Of Disciplinary Hearing - Arizona Department Of Liquor Licenses And Control

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State of Arizona Department of Liquor Licenses and Control
800 W. Washington, 5th Floor
Phoenix, AZ 85007
(602)542-5141
REQUEST FOR NOTICE OF DISCIPLINARY HEARING
NOTE: THIS DOCUMENT IS TO BE SIGNED BY AN AUTHORIZED NEIGHBORHOOD REPRESENTATIVE.
INTERESTED NEIGHBORHOOD ASSOCIATION DATA:
Neighborhood Association Name:
Authorized Neighborhood Association Representative:
Last
First
Middle
Mailing Address:
Address
City
State
Zip
Business Phone: (
)
Residence Phone: (
)
This statement is led in accordance with A.R.S. §4-201(E).
State of
County of
X
The foregoing instrument was acknowledged before me this
(Signature of Authorized Neighborhood Representative)
d
y a
f o
,
Day
Month
Year
M
y
o c
m
i m
i s s
n o
x e
p
r i
s e
o
: n
(Signature of NOTARY PUBLIC)
LICENSEE DATA :
(This information may be obtained via our web site at )
Licensee/Applicant's Name: (Exactly as it appears on license/application)
Last
First
Middle
Mailing Address:
Address
City
State
Zip
License Location: (Exactly as it appears on the license/application)
Address
City
State
Zip
License Number:
Phone Number: (
)
*Disabled individuals requiring special accommodations, please call the Department.
updated 10/28/2013

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