Application For Brokerage Representative/salesman Permit For Spirituous Liquor
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1
2PLEASE
Permit No. ________
Date Issued: _______
ATTACH
North Carolina
Alcoholic Beverage Control Commission
A RECENT
Mailing Address: 4307 Mail Service Center, Raleigh, NC 27699-4307
Location: 400 East Tryon Road, Raleigh, NC 27610
PHOTO
Phone: (919) 779-0700 Fax: (919) 661-5927
Application for
Brokerage
Representative/
Salesman
Permit for
Spirituous Liquor
:
Application Requirements
A. Include a recent photo
B. Include a Certified Criminal Record Check or a certified copy of a
court record(s) from the last jurisdiction where you have maintained
residence for one year or more. If there is no record, please have the
clerk of the court in the jurisdiction so certify.
C. This form MUST be Notarized (second page)
1. Name of the
Brokerage
you represent:
Division (if applicable) _______________________ Date of employment
: _____________________
2. Territory responsible for:
_________________________________________________________________
3. Name (
):
PRINT
4. Mailing Address:
________________________________________________________________________
5. E-mail Address (Required):
______________________________________________________________
6. Phone No: (
)
Driver's License
__________________________
No: __________________________
7. Social Security No.– LAST FOUR (4) DIGITS
Date of birth:
. ______________
___________________
8. Address of last place of residence for period of one year or more:
__________________________________________________________________________________________
__________________________________________________________________________________________
9. Spouse's Name (if applicable):
_____________________________________________________________
Spouse's Address (if different from above):
__________________________________________________
_________________________________________________________________________________________
10. Are you (or your spouse) related to any state or local ABC Board Member or the employees thereof?
____Yes ____No
If yes, Name, relationship, and their address.
a. _______________________________________________________________________________________
b. _______________________________________________________________________________________
11. Do you now or have you (or your spouse) previously held any type of permit(s) issued by the North
Carolina Alcoholic Beverage Control Commission? If so, for each permit indicate the date and name
of the business licensed, and, if applicable, the reason the permit is no longer held.
a. _______________________________________________________________________________________
b. _______________________________________________________________________________________
Revised 4/2008
(Formerly Application for Spirituous Liquor Representative's Permit)
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