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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
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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
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