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Record Of Wine Or Malt Beverage Delivery - Oregon

Record Of Wine Or Malt Beverage Delivery Form. This is a Oregon form and can be used in Liquor Control Commission Statewide .
 Fillable pdf Last Modified 4/2/2007
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OREGON LIQUOR CONTROL COMMISSION RECORD OF WINE OR MALT BEVERAGE DELIVERY Please Print or Type Licensee ____________________________________________________________ Trade Name _________________________________________________________ Date of Request: ______________________________________________________ I delivered malt beverages or wine to: Name _____________________________________________ Address ___________________________________________ Date & Time ________________________at ______________ I verified the age of this person (if they looked under 26 years old) by one of the following methods. 1. Driver's License Number _____________________ State ___________ 2. State-issued Identification Card Number ________________________ State __________ 3. Completed S-146 card attached. Brand of Alcohol _________________________ _________________________ _________________________ Quantity ___________ ___________ ___________ Price (alcohol) Price (food) [same day delivery only] ___________ ___________ ___________ _________ _________ _________ I certify that I delivered to the above-named person and that he/she is at least 21 years of age and is not visibly intoxicated. _____________________________________ Common Carrier Delivery Person _____________________________________ Service Permittee _________________________ Common Carrier Company _________________________ Service Permit Number 1-800-452-OLCC (6522) www.olcc.state.or.us (rev. 08/04) American LegalNet, Inc. www.FormsWorkflow.com
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