Arizona > Statewide > Liquor Licenses And Control
File Deactivation Form LIC0050 - Arizona
| File Deactivation Form 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 & CONTROL 400 W Congress #521 800 W Washington 5th Floor Tucson AZ 85701-1352 Phoenix AZ 85007-2934 (520) 628-6595 (602) 542-5141 FILE DEACTI VATION FORM Print and Use Black Ink Only I. TYPE OF ACTION LICENSE SURRENDER, COMPLETE SECTION II, PUT REASON ON REVERSE. APPLICATION WITHDRAWAL, COMPLETE SECTION II, PUT REASON AT BOTTOM OF FORM. USE ADDITIONAL SHEET IF NECESSARY II. LICENSE DATA LICENSE NUMBER LICENSEE BUSINESS NAME MAILING ADDRESS _____________________________________ SIGNATURE OF LICENSEE/APPLICANT State of____________________County of The foregoing instrument was acknowledged before me this ______ OF _____________, DAY MONTH YEAR _____________________________________ SIGNATURE OF NOTARY PUBLIC My commission expires ______ OF _____________, DAY MONTH YEAR III. DISPOSITIONS LETTER ATTACHED REVOKED-ORDER #__________________ REVERTED-ORDER #_________________ FAILED TO RENEW APPLICATION DENIED # APPLICATION WITHDRAWN IV. REVIEW RECEIVED BY BACKGROUND INVEST. (Pending Apps Only) LICENSING SUPERVISOR LCS TECHNICIAN LIQUOR BOARD EMPLOYEE DATE REASON FOR WITHDRAWAL USE ADDITIONAL SHEET IF NECESSARY **Disabled individuals requiring special accommodations, please call 542-9027 lic0050 05/2004 American LegalNet, Inc. www.FormsWorkflow.com
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