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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 9/7/2015
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Arizona Department of Liquor Licenses and Control 800 W Washington 5th Floor Phoenix, AZ 85007-2934 (602) 542-5141 FOR DLLC USE ONLY Date: Approved by: Business Information / Name Change Request (No Fees Required) 1. 2. 3. License Number: ___________________________________________ Individual / Agent Name:___________________________________________________________________________________ Last First Middle 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 Location Address: NOTE: THIS IS NOT A LOCATION TRANSFER, THIS IS A LOCAL GOVERNMENT OR U.S. POSTAL AUTHORIZED ADDRESS CHANGE, DOCUMENTATION MUST BE ATTACHED. ____________________________________________________________________________________________________________________ Street City State Zip New Business Phone: _________________________ Daytime Contact Number: ___________________________ City State Zip New Mailing Address: ______________________________________________________________________________________ Street Other (please explain): _____________________________________________________________________________________ (Attach additional sheet in necessary) , hereby declare that an AUTHORIZED PERSON filing I, (Print Full Name) this request. I have read this document and the contents and all statements are true, correct and complete. X (Signature) State of ________________County of _________________ My commission expires on: __________________ The foregoing instrument was acknowledged before me this ____________ of ______________________ _____________ Day Month Year ___________________________________________________ Signature of NOTARY PUBLIC 7/15/2015 Page 1 of 1 Individuals requiring ADA accommodations please call (602)542-9027 American LegalNet, Inc.
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