Ohio > Statewide > Department Of Commerce > Division Of Liquor Control
Club Officers Statement DLC 4050 - Ohio
| Club Officers Statement Form. This is a Ohio form and can be used in Division Of Liquor Control Department Of Commerce Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
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 SECTION A. CLUB OFFICERS STATEMENT DBA Name City Federal Tax Identification No. State OHIO Zip Code Name of D4 Applicant Permit Premises Address Township, if in Unincorporated Area LIST TOP FOUR OFFICERS: NAME OFFICE HELD RESIDENCE ADDRESS SSN DOB Affidavit Affidavit Being first duly sworn according to law, depose and say: *The above-listed individuals are the current elected and controlling officers of the Club. *The Club was organized solely for and in the interest of the membership of a reputable organization, and not for the profit of any person, firm, or company, either directly or indirectly. *Only members in good standing can and are permitted to exercise the privileges of the Club. *The telephone number of the Club premises is ____(_____)___________________________________________________ . *The Club was organized for the purpose of: Fraternal Benevolent Social Charitable Recreational Political Regular Special meetings. Athletic Patriotic *Membership in the Club is subject to the consent and approval of the membership at *The yearly initiation fee is $_______________________. *The dues of $______________ are payable Weekly Monthly Quarterly Semi-Annually Yearly. State of Ohio, __________________________County, ss: ____________________________________________________________________, being first duly sworn according to law, (Print Name) deposes and says that he/she is duly elected and qualified as the___________________________________________ of the ___________________________________________. (Club Name) TO BE COMPLETED BY NOTARY: __________________________________________ (Signed) (Office Held) Sworn to before me and subscribed in my presence this _____ day of ___________________ 20_______. (Date) (Month) (Year) Rev. 5/06 (Notary Public) (Expiration Date) American LegalNet, Inc. www.FormsWorkflow.com
|
|||||||
