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Business Information Name Change Request LIC0111 - Arizona

Business Information Name Change Request Form. This is a Arizona form and can be used in Liquor Licenses And Control Statewide .
 Fillable pdf Last Modified 1/11/2010
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ARIZONA DEPARTMENT OF LIQUOR LICENSES & CONTROL 800 W Washington 5th Floor Phoenix AZ 85007-2934 (602) 542-5141 400 W Congress #521 Tucson AZ 85701-1352 (520) 628-6595 BUSINESS INFORMATION/NAME CHANGE REQUEST (No Fees Required) 1. License Number: 2. Licensee/Agent's Name: Last First Middle 3. Current Business Name: (Exactly as it appears on the license) For all changes that apply to you, please check applicable boxes and complete: New Business Name: New Business Address: NOTE: THIS IS NOT A LOCATION TRANSFER. THIS IS ONLY A LOCAL GOVERNMENT OR U.S. POSTAL AUTHORIZED ADDRESS CHANGE. DOCUMENTATION MUST BE ATTACHED. Street City State Zip New Business Phone: ( New Mailing Address: ) New Home Phone ( ) Street City State Zip Other (please explain): (Attach additional sheet if necessary) I, (Print full name) , hereby declare that I am an AUTHORIZED PERSON filing this request. I have read this document and the contents and all statements are true, correct and complete. State of County of The foregoing instrument was acknowledged before me this X (Signature) Day Month Year My commission expires on: (Signature of NOTARY PUBLIC) DEPARTMENT USE ONLY Approved by: Date: *Disabled individuals requiring special accommodation, please call the Department. LIC0111 05/2004 American LegalNet, Inc. www.FormsWorkflow.com
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