Form Altret - Alteration Request Form printable pdf download

Form Altret - Alteration Request Form

MONTANA

AltRet

New 01 11

Alteration Request Form

(Retail Licensees Only)

Section 1 – General Information

Name of Licensee(s) _________________________________________________________________________

License Number

Doing Business As ___________________________________________________________________________

Contact Person _____________________________________________________________________________

Telephone _________________________________________________________________________________

Fax _______________________________________________________________________________________

Cell Phone _________________________________________________________________________________

E-mail Address _____________________________________________________________________________

Physical Address of Premises __________________________________________________________________

(Street Address, City, State, Zip Code)

Mailing Address _____________________________________________________________________________

(Street Address, City, State, Zip Code)

Section 2 – Proposed Alteration

Please give a short description below of your proposed alteration or remodel.

__________________________________________________________________________________________

Section 3 - Continuation of operations during alterations

Please check below whether you will continue or discontinue operations during the alteration.

_____ I will continue operations during the alterations of my premises. Please return the suitability checklist (enclosed).

_____ I will discontinue operations during the alterations of my premises. Please place my license on nonuse status.

*11NM0101*

Form Altret - Alteration Request Form