New Jersey > Statewide > Division Of Alcoholic Beverage Control

Representation And Statement Of Age For Purchase Of Alcohoic Beverages - New Jersey

Representation And Statement Of Age For Purchase Of Alcohoic Beverages Form. This is a New Jersey form and can be used in Division Of Alcoholic Beverage Control Statewide .
 Fillable pdf Last Modified 4/5/2007
Get this form for FREE as a print-only pdf

REPRESENTATION AND STATEMENT OF AGE FOR PURCHASE OF ALCOHOLIC BEVERAGES I understand that misrepresentation of age to induce the sale, service or delivery of alcoholic beverages to me is cause for my arrest, prosecution and punishment which can result in: 1. payment of a fine not less than $500 ­ nor more than $1,000; possible imprisonment up to 6 months; mandatory loss or deferment of driver's license privileges for 6 months; a requirement to participate in an alcohol education or treatment program for a period not to exceed 6 months. I hereby 2. 3. 4. Knowing the possible penalties for misstatement, represent and state for the purpose of inducing _____________________________________________ (Name of Licensee) _____________________________________________ (Address of Licensed Premises) to sell, serve or deliver alcoholic beverages to me, that I was born ________________________ (Month) ____________________ (Day) ___________ (Year) and I am _________________ years of age. Date_________________________ Signed___________________________ Address___________________________ ___________________________ American LegalNet, Inc. www.FormsWorkflow.com OTHER IDENTIFICATION PRESENTED: Non-Photo Driver's License ­ Number and State _____________________________________________ Photo Driver's License ­ Number and State _____________________________________________ County Photo ID ­ Number and County _____________________________________________ Credit Card ­ Company and Number _____________________________________________ Draft Registration ­ Number and Date _____________________________________________ Other ­ Specify _____________________________________________ Signature of person who witnessed completion of this statement by patron. ____________________________________________ (Signature) State of New Jersey Department of Law and Public Safety Division of Alcoholic Beverage Control 140 East Front Street, P.O Box 087 Trenton, NJ 08625-0087 07/03 American LegalNet, Inc. www.FormsWorkflow.com
Link/Embed this Document
URL
Embed


Popular Searches

  1. garnishment
  2. Unlawful Detainer
  3. contempt
  4. small claims
  5. Adoption
  6. appearance
  7. small estate affidavit
  8. motion to vacate
  9. eviction
  10. Pro Hac Vice

Bookmark and Share