Form Dbpr Abt-6002 - Examination Application For Multiple License Locations Page 9
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13SECTION 10 - AFFIDAVIT OF TRANSFEROR
NOTARIZATION REQUIRED
Trade Name (D/B/A)
“I, the undersigned, hereby swear or affirm that I am duly authorized to make this affidavit and do hereby
consent, on my behalf or on behalf of the transferor, to the above transfer, and represent to the Division of
Alcoholic Beverages and Tobacco that the license which is being transferred is as shown in the application,
and that a bona fide sale in good faith or change in ownership has been made to the within applicant of the
businesses for which the foregoing transfer of a license is sought.”
STATE OF___________________
_________________________________________________
TRANSFEROR OR AUTHORIZED OFFICER SIGNATURE
COUNTY OF_________________
_________________________________________________
TRANSFEROR OR AUTHORIZED OFFICER 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
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