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Cancellation Request - Ohio
| Cancellation Request 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 ยท P.O. Box 4005 Reynoldsburg, OH 43068-9005 (614) 644-3155 FAX (614) 644-3166 http://www.com.state.oh.us CANCELLATION REQUEST Date: Re: Permit Number: Permit Name: Permit Address: Permit State: Permit City: Permit Zip Code: Permit Class(es) to be Canceled: SECTION A : Complete this section to Cancel a Pending Application with the Division of Liquor Control. (Please mark the appropriate box): Please cancel the above captioned New Application class(es), and REFUND PERMIT FEE ON DEPOSIT. Please retain the above captioned New Application class(es) on the waiting list, and REFUND PERMIT FEE ON DEPOSIT. Please cancel the above captioned pending Transfer Application, WITHOUT REFUND of your Processing Fee. (Signature of person who signed the application originally submitted to the Division): X Skip "Section B", and complete "Section C" below. SECTION B : Complete this section to Cancel Issued Permit Class(es) Pursuant to Ohio Administrative Code 4301:1-1-15, I hereby request that the Division of Liquor Control CANCEL, WITHOUT REFUND the issued permit number and class(es) captioned above. In order to cancel your permit without refund, please submit your Permit and Permittee Identification Card with this request. If you do not have your Permit and/or Identification Card, please submit an affidavit explaining why it/they cannot be returned to the Division. (Signature of Permit Holder): X (Date): (Date): SECTION C: THE SIGNATURE AND MAILING ADDRESS BELOW IS REQUIRED WHETHER YOU ARE CANCELING A PENDING APPLICATION OR AN ISSUED PERMIT. WITHOUT THIS INFORMATION THE DIVISION WILL BE UNABLE TO PROCESS YOUR CANCELLATION AND/OR SUBMIT A REFUND, IF APPLICABLE. (Print Name): (Telephone Number): (Mailing Address): State: (Social Security Number): City: Zip Code: Rev. 3-18-09 FINANCIAL INSTITUTIONS REAL ESTATE AND PROFESSIONAL LICENSING INDUSTRIAL COMPLIANCE SECURITIES LABOR & WORKER SAFETY STATE FIRE MARSHAL LIQUOR CONTROL UNCLAIMED FUNDS American LegalNet, Inc. www.FormsWorkFlow.com "An Equal Opportunity Employer and Service Provider"
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