Application For Brokerage Representative/salesman Permit For Spirituous Liquor Page 2

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12. Required: Previous employers - Name, address, telephone number, and dates of employment
a. _______________________________________________________________________________________
b. _______________________________________________________________________________________
c. _______________________________________________________________________________________
13. Provide name, address and telephone number of two (2) references:
a. _______________________________________________________________________________________
b. _______________________________________________________________________________________
14. Have you ever been convicted of violating any criminal law? ____Yes ____No
If yes, give
reason for conviction:
_________________________________________________________________________________________
_________________________________________________________________________________________
15. Attach a 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.
By signing this request for a
Brokerage Salesman
Permit, you fully understand that, if issued, this
permit can, at the discretion of the Commission, be revoked, suspended or annulled at any time.
_____________________________________________________________________________________________
Signature
Date
Sworn to and subscribed before me on this the __________day of ________________20________
My commission expires
: ____________________________________________________
__________________________________________
Notary
Mail to:
ATTN: Cathy Horne
North Carolina ABC Commission
400 East Tryon Road
Raleigh NC 27610
10/18/2017
2

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