Form Dbpr Abt-6002 - Examination Application For Multiple License Locations Page 7
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139
Are you an official with State police powers granted by the Florida Legislature?
Yes
No
If yes, provide details:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_______________________________________________________________________________
NOTARIZATION STATEMENT
“I swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791, 562.45 and
837.06, Florida Statutes, that I have fully disclosed any and all parties financially and or contractually
interested in this business and that the parties are disclosed in Section 12 of this application. I further swear
or affirm that the foregoing information is true and correct.”
STATE OF___________________
_________________________________________________
APPLICANT SIGNATURE
COUNTY OF_________________
_________________________________________________
APPLICANT SIGNATURE
The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this _______Day
of______________, 20_____, By_____________________________________ who is ( ) personally known
to me OR ( ) who produced ______________________________________________as identification.
________________________________________________ Commission Expires: ___________________
Notary Public
(ATTACH ADDITIONAL COPIES AS NECESSARY)
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