Ohio > Statewide > Department Of Commerce > Division Of Liquor Control
Non Profit Entity Disclosure Form DLC 4029 - Ohio
| Non Profit Entity Disclosure Form Form. This is a Ohio form and can be used in Division Of Liquor Control Department Of Commerce Statewide . |
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OHIO DEPARTMENT OF COMMERCE - DIVISION OF LIQUOR CONTROL 6606 Tussing Road, P.O. Box 4005, Reynoldsburg, Ohio 43068-9005 FOR OFFICE USE ONLY NEW PERMIT # TRANSFER Telephone: (614) 644-2431 - http://www.com.state.oh.us NON PROFIT ENTITY DISCLOSURE FORM Section A (This form should be used by all non profit businesses, municipal corporations and educational institutions organized not for profit.) DBA Name City, State Tax Identification No. (TIN) Name of Non Profit Entity Permit Premises Address Township, if in Unincorporated Area Zip Code Please be advised that any social security numbers provided to the Division of Liquor Control in this application may be released to the Ohio Department of Public Safety, the Ohio Department of Taxation, the Ohio Attorney General, or to any other state or local law enforcement agency if the agency requests the social security number to conduct an investigation, implement an enforcement action, or collect taxes. SECTION B. If the non profit entity has officers, indicate the top five individuals. If there are no officers, please indicate by writing NONE. NAME OF OFFICER 1) CEO 2) President 3) Vice-President 4) Secretary 5) Treasurer SOCIAL SECURITY NUMBER DATE OF BIRTH SECTION C. Indicate the officer or individual who is responsible for overseeing the food and beverage service operations of the business/organization. THE INDIVIDUAL LISTED BELOW MUST SUBMIT A CIVILIAN IDENTIFICATION CARD & PERSONAL HISTORY BACKGROUND FORM Name Residence Address City and State Telephone No. Social Security No. (if individual) Zip Code Date of Birth STATE OF OHIO, ___________________________________________ COUNTYss, I, ____________________________________________________being first duly sworn, according to law, deposes and says that he/she is (Title) _____________________ of the ______________________________________________, a business duly authorized by law to do business in the State of Ohio, and that the statements made in the forgoing affidavit are true. (Signature) ___________________________________________________ (Print Name and Title) _______________________________________________________ Sworn to and subscribed in my presence this __________________ day of _____________________________________________________, _______________________ ___________________________________________________________ (Notary Public) (Notary Expiration) DLC 4029 EOE/ADA SERVICE PROVIDER FOR TTY USERS DIAL 1-800-750-0750 REV. 2-15-06 American LegalNet, Inc. www.FormsWorkflow.com
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