Mississippi > Statewide > State Tax Commission > Office Of Alcoholic Beverage Control
Affidavit And Application For Class I Temporary Permit - Mississippi
| Affidavit And Application For Class I Temporary Permit Form. This is a Mississippi form and can be used in Office Of Alcoholic Beverage Control State Tax Commission Statewide . |
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ABCD 1999T1 (REVISED 06/10) APPLICATION, CLASS 1 TEMPORARY RETAILER'S PERMIT ALCOHOLIC BEVERAGE CONTROL PERMIT DEPARTMENT P.O. BOX 540 MADISON, MS 39130-0540 RETURN TO American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR PROPER FILING OF YOUR APPLICATION PLEASE READ PRIOR TO COMPLETING THIS APPLICATION 1. The application fee is $35.00 and must be in the form of a cashier's check or money order payable to the Alcoholic Beverage Control. This payment must be returned with this completed application. (NOTE: IF YOUR EVENT IS FOR MORE The applicant's signature must be notarized by a licensed Notary Public. The alcoholic beverages used by you under this permit must be purchased from a licensed package retailer located in the same county as your event. This application, with fee, must be received by the Alcoholic Beverage Control at least two (2) weeks prior to the event to assure adequate time for the processing and mailing of your permit. THAN ONE DAY, THEN THE PAYMENT MUST TOTAL $35.00 PER DAY). 2. 3. 4. If you have questions, or need assistance, please call the ABC Permit Department (601) 856-1330 American LegalNet, Inc. www.FormsWorkFlow.com PERMIT DEPT. USE ONLY AMT. OF CHECK CHECK NO. PERMIT NO. APPLICATION AND AFFIDAVIT FOR CLASS 1 TEMPORARY PERMIT I. APPLICANT: Name (Nonprofit civic or charitable organization) Address: (street or post office box) (city) (state) (zip) Person responsible for event: Telephone Number: (area code) (phone number) II. EVENT: (Type of event) Date: (month) (day) (year) Hours of event: (beginning) Location: (actual location) (ending) Address: (street) (city) (zip) Location is __ inside __ outside the corporate city limits? III. LIST THE PACKAGE STORE(S) FROM WHICH THE ALCOHOLIC BEVERAGES USED IN THIS EVENT WILL BE OBTAINED: Business Name: Address: (street) (city) (zip) IV. Has any officer or director of the organization ever been convicted of any of the following: a felony in any state or federal court OR violation of the "Local Option Alcoholic Beverage Control Laws" of the State of Mississippi OR violation of any law relating to alcoholic beverages, beer If "yes", explain fully: or light wine? American LegalNet, Inc. www.FormsWorkFlow.com PERMITTEE CERTIFICATION AND OATH I, , certify under penalty of perjury that the organization applying for the Temporary Class 1 Permit is a bona fide nonprofit civic or charitable organization and, as such, does meet the qualifications of Section 67-1-11, 67-1-37, 67-1-51 (2) and (3), 67-1-55, 67-1-57 (excluding paragraph (e)) and 67-1-59. I affirm that this organization, in the exercise of this permit, will comply with the Local Option Alcoholic Beverage Control Laws, Rules, and Regulations, relative to the purchase, sale, and handling of alcoholic beverages and will keep all records and make all reports and remittances as required thereby. I certify that the information presented on the application is true and correct, to the best of my knowledge and belief. BY: TITLE DATE NOTARY State of Mississippi County of THIS DAY, personally came and appeared before me, the undersigned authority in and for the county and state aforesaid, the within named who, after being by me first duly sworn, states on oath that the matters and things contained and set forth in the foregoing application are true and correct. SWORN TO AND SUBSCRIBED before me, this the ____day of_________________,___. Notary Public My commission expires: American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com
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