Renewal Application Form Page 2
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2(OWNERSHIP, OFFICERS, LOCATION, &c.)?
If yes, please explain: __________________________________________________________
____________________________________________________________________________
V. HAVE ALL YOUR ALCOHOLIC BEVERAGE SERVICE EMPLOYEES APPLIED FOR AN
IDENTIFICATION CARD AS REQUIRED BY ABC REG. NO. 39?
_
YES
_
NO
VI. ATTACH A COPY OF YOUR CURRENT FEDERAL ALCOHOL RETAILERS STAMP
OR YOUR CANCELLED CHECK AS PROOF OF APPLICATION FOR SAME.
VII. ATTACH A COPY OF YOUR DEED OR CURRENT LEASE
.
VIII. SUPPLEMENTAL INFORMATION, ON-PREMISES RETAILERS & CATERERS.
AMOUNT
PERCENTAGE
a. Lodging income
$ ________________
_________
b. Food sales income
$ ________________
_________
c. Beer sales income
$ ________________
_________
d. Alcoholic beverage sales income
$ ________________
_________
e. Other income
$ ________________
_________
Number of months used in the above sales summary: _____________
Manager
___________________________ SSN __________________
(on premises sales)
SIGNATURE: ____________________________________
TITLE: ____________________________________
DATE: _______________________
NOTARY
STATE OF MISSISSIPPI
COUNTY OF ___________________
THIS DAY personally appeared before me, the undersigned authority in and for the aforesaid jurisdiction, the within named
___________________________________ who, after being by me first duly sworn, states on oath that the matters and
things contained and set forth in the above application are true and correct as stated therein.
Sworn to and subscribed before me, this the _____day of _____________, 19______.
_______________________________________
NOTARY PUBLIC
MY COMMISSION EXPIRES; __________________________________
IMPORTANT
PERMIT RENEWALS ARE DUE IN OUR OFFICE
30 DAYS PRIOR TO EXPIRATION. THEREFORE
YOUR RENEWAL IS DUE ON OR BEFORE:
__________________________________________
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