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Statement Re Consideration Points ABC-251 - California

Statement Re Consideration Points Form. This is a California form and can be used in Department Of Alcoholic Beverage Control Statewide .
 Fillable pdf Last Modified 1/10/2011
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Department of Alcoholic Beverage Control STATEMENT RE: CONSIDERATION POINTS State of California Edmund G. Brown Jr., Governor Applicant: Please complete left side of form, then sign. List the names and addresses of all schools, churches, hospitals, public playgrounds, parks, and youth facilities located within 600 feet of your proposed premises. Measure all distances by direct line from the closest edge of the facility structure to the closest edge of your structure. Continue on reverse if needed. 1. APPLICANT NAME 2. PREMISES ADDRESS (Street number and name, city, zip code) 3. FACILITY NAME/ADDRESS LTR PERS DATE DEPARTMENT USE ONLY DISTANCE FT. NAME SEPARATION FACTORS 1. LTR PERS DATE FT. 2. NAME LTR PERS DATE FT. 3. NAME LTR PERS DATE FT. 4. NAME LTR PERS DATE FT. 5. NAME LTR PERS DATE FT. 6. NAME LTR PERS DATE FT. 7. NAME LTR PERS DATE FT. 8. NAME LTR PERS DATE FT. 9. NAME I acknowledge that any false, misleading or omitted information required in this statement may constitute grounds for denial of the application for the license, or, if the license is issued in reliance upon information in this statement which is omitted, false or misleading, then such misinformation or omission will constitute grounds for revocation of the license so issued. 4. APPLICANT SIGNATURE DATE SIGNED ABC-251 (rev. 01-11) American LegalNet, Inc. www.FormsWorkFlow.com
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