Arizona > Statewide > Liquor Licenses And Control
Application For Direct Shipment License LIC1026 - Arizona
| Application For Direct Shipment License Form. This is a Arizona form and can be used in Liquor Licenses And Control Statewide . |
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Arizona Department of Liquor Licenses and Control 800 W Washington 5th Floor Phoenix AZ 85007-2934 www.azliquor.gov (602) 542-5141 APPLICATION FOR DIRECT SHIPMENT LICENSE IMPORTANT INFORMATION This license, held simultaneously with an Arizona producer license, adds the privilege of taking orders from retail consumers by phone, internet, email, fax, or in person provided that the order is shipped directly to an Arizonalicensed distributor, then to an Arizona-licensed retailer before consumer receipt. SECTION 1 Application type: SECTION 2 Ownership type: New License Individual Partnership Agent Change Corporation Name _____________________________________ SECTION 3 Fee: A DIRECT SHIPMENT LICENSE IS VALID FOR THREE YEARS. DIRECT SHIPMENT LICENSES MAY NOT BE RENEWED OR TRANSFERRED. A PERSON WHO HOLDS A DIRECT SHIPMENT LICENSE MAY APPLY FOR A NEW LICENSE NOT MORE THAN NINETY DAYS BEFORE EXPIRATION OF A CURRENT LICENSE. LICENSE FEE: $25.00 A service fee of $25 will be charged for all dishonored checks (A.R.S. §44-6852) SECTION 4 Application 1. Applicant/Agent's Name: ______________________________________________________________ (Insert one name ONLY to appear on license) First Last Middle 2. Business Name: _____________________________________________________________________ (Exactly as it appears on the exterior of premises) 3. Business Address: ___________________________________________________________________ (Do not use PO Box) Street City State Zip 4. Mailing Address: ____________________________________________________________________ (All correspondence will be mailed to this address) Street City State Zip 5. Business Phone: (____)____________________ 6. Federal ATF Permit #: _____________________ Residence Phone: (____)____________________ Your State License #: ______________________ ATTACH A COPY OF YOUR LICENSE THAT PERMITS YOU TO DEAL IN SPIRITUOUS LIQUOR IN YOUR HOME STATE SECTION 5 All questions MUST be answered. 1. Have you EVER had an application for any business, profession, or liquor license rejected, Yes No denied, suspended, or revoked? 2. Has anyone EVER filed suit or obtained a judgment against you in an civil action, the subject of which involved fraud or misrepresentation of a liquor license? Yes No 3. Have you EVER had a criminal conviction in any state or foreign jurisdiction? 10/17/12 Yes No (continued on back) Disabled individuals requiring special accommodations please call (602)542-9051 American LegalNet, Inc. www.FormsWorkFlow.com 4. If you have answered "yes" to questions 1, 2, or 3 of this section, give complete details and attach an additional sheet if necessary _________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 5. Are you familiar with Arizona state liquor laws and regulations? (A.A.C. R19-1-105) 6. Do you agree to notify the Department of Liquor of any proposed changes to ownership or information provided on your original application prior to making any such changes? 7. Do you agree to keep all records, invoices, and other documents relating to the purchase, sale or delivery of spirituous liquor for a period of two years and to keep those records easily accessible for examination? 8. Do you consent to an investigation of your background including records of every kind and description including police records and to waive rights or causes of action that you may have against the Department of Liquor Licenses and Control, other individual or agency that may disclose or release information to the Department? Yes No Yes No Yes No Yes No 9. If you have answered "no" to questions 5, 6, 7 or 8 of this section, give complete details and attach an additional sheet if necessary _________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ FALSE OR INCOMPLETE ANSWERS COULD RESULT IN THE DENIAL OR SUBSEQUENT REVOCATION OF A LICENSE OR PERMIT SECTION 5 WHOLESALER/DISTRIBUTOR INFORMATION 1. Provide the names and addresses of the wholesaler(s)/distributor(s) licensed in Arizona that have received shipments from you within the previous three years and the number of shipments made to each. Attach a separate sheet. 2. Provide the names and addresses of the non-licensed wholesaler(s)/distributor(s) in Arizona that have received shipments from you within the previous three years and the number of shipments made to each. Attach a separate sheet. IMPORTANT INFORMATION This license, held simultaneously with an Arizona producer license, adds the privilege of taking orders from retail consumers by phone, internet, email, fax, or in person provided that the order is shipped directly to an ArizonaI, ___________________________________________, declare before consumer receipt. licensed distributor, then to an Arizona-licensed retailer that: (Print name) I __________________________________ , hereby declare that I am the APPLICANT filing this (printed name) application. I have read this application, the contents and Declare that all statements are true, correct and complete. I acknowledge that shipment into Arizona contrary to A.R.S. §4-203.04 will result in the immediate suspension of the Direct Shipment License. _________________________________________ (signature of applicant) NOTARY State of _______________County of ______________________ state county day month year The foregoing instrument was acknowledged before me this _____ day of ________________, _______. My commission expires on _________________ day/ month/year ___________________________________________ signature of NOTARY PUBLIC American LegalNet, Inc. www.FormsWorkFlow.com
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