SECTION 15 - CURRENT LICENSEE UPDATE DATA SHEET
This section is to be completed for all current alcoholic beverage and/or tobacco license holders listed on the
application to ensure the most up to date information is captured.
Trade Name (D/B/A)
Last Name
First
Middle
Current License Number(s)
Date of Birth
Social Security Number*
_____/_____/_______
Street Address
City
State
Zip Code
Last Name
First
Middle
Current License Number(s)
Date of Birth
Social Security Number*
_____/_____/_______
Street Address
City
State
Zip Code
Last Name
First
Middle
Current License Number(s)
Date of Birth
Social Security Number*
_____/_____/_______
Street Address
City
State
Zip Code
Last Name
First
Middle
Current License Number(s)
Date of Birth
Social Security Number*
_____/_____/_______
Street Address
City
State
Zip Code
13