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Gifts And Loans From Wholesalers Disclosure Form - District Of Columbia

Gifts And Loans From Wholesalers Disclosure Form Form. This is a District Of Columbia form and can be used in Alcoholic Beverage Regulation Administration Statewide .
 Fillable pdf Last Modified 3/23/2007
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GOVERNMENT OF THE DISTRICT OF COLUMBIA Alcoholic Beverage Regulation Administration 23 DCMR § 904 Gifts and Loans from Wholesalers Disclosure Form -- Please Print or Type All Information ­ Name of entity contributing the § 904 item or service. DATE: _________________________________ of 904 Event TO: Alcoholic Beverage Regulation Admin. ATTN: Director of Operations/904 Filing 941 North Capitol St., NE, Room 7200 Washington, D.C. 20002 VIA Fax ­ 202/442-9563 Via E-mail ­ Jeff.Coudriet@dc.gov FROM: _________________________________ (License #) _________________________________ (Trade Name) _________________________________ (Address) _________________________________ Please note, pursuant to 23 DCMR § 904.3, Board approval is not required for an individual transmittal having a value of less than fifty dollars ($50). A. Pursuant to 23 DCMR § 904, the applicant requests permission to distribute the following item or service to licensees: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ B. The item/service is a (circle one): Purchase Rental Loan Gift C. Value of item: ________________ D. Each licensee listed (if multiple 904 events) has received the exact same item/service as described above. E. We certify that no licensee will receive items of value that exceed $500.00 for each separate service or article of property for each individual occurrence. F. List the name of licensee(s) receiving the 904 item or service described above. Check here if list detailing this information is attached. License # Trade Name Address _____________________________________________________ Signature Date American LegalNet, Inc. www.FormsWorkflow.com
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