Application For A Brokerage Permit For Spirituous Liquor (Page 2 of 2) in pdf

Application For A Brokerage Permit For Spirituous Liquor Page 2

10. Have you ever been convicted of violating any criminal law? ____Yes ____No

If yes, give

reason for conviction:

_________________________________________________________________________________________

11.

Suppliers you plan to represent: ________________________________________________________

_________________________________________________________________________________________

12.

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.

Brokerage

By signing this request for a

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

5/14/2014

Application For A Brokerage Permit For Spirituous Liquor Page 2