File Deactivation Form {LIC0050} | Pdf Fpdf Doc Docx | Arizona

File Deactivation Form {LIC0050}

File Deactivation Form {LIC0050} | Pdf Fpdf Doc Docx | Arizona

File Deactivation Form Form

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This is a Arizona form that can be used for Liquor Licenses And Control within Statewide.

Last updated: 3/24/2017
Arizona Department of Liquor Licenses and Control 800 W Washington 5th Floor Phoenix, AZ 85007-2934 (602) 542-5141 FILE DEACTIVATION FORM Print and use black ink only 1. DLLC USE ONLY Date: Processed by: LICENSE SURRENDER APPLICATION WITHDRAWAL LICENSE DATA: LICENSE NUMBER: _____________________________________ CONTROLLING PERSON / AGENT NAME: ______________________________________________________________________________ BUSINESS LOCATION NAME: _________________________________________________________________________________________ BUSINESS LOCATION ADDRESS: ______________________________________________________________________________________ MAILING ADDRESS: _________________________________________________________________________________________________ REASON FOR WITHDRAWAL/SURRENDER TYPE OF ACTION: 2. ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ USE BACK OF PAGE IF NECESSARY I, (Print Full Name) , hereby declare that I am a CONTROLLING PERSON and/or AGENT filing this notification. I have read this document and the contents and all statements are true, correct and complete. X (Signature) ______________________________________________ Controlling Person / Agent State of ____________________County of ____________________ The foregoing instrument was acknowledged before me this My commission expires on: _______________________ ____________ of ______________________ ____________ Day Month Year FOR DLLC USE ONLY __________________________________________________ Signature NOTARY PUBLIC INVESTIGATIVE REVIEW DEPARTMENT PROTEST Requires Director or Designate and Chief of Investigations or Designate approvals DIRECTOR APPROVAL CHIEF OF INVESTIGATIONS APPROVAL YES YES NO _________________________________________ NO _________________________________________ EMPLOYEE DATE __________________ __________________ __________________ __________________ __________________ REVIEW Received by Background Investigator (pending app.'s only) Licensing Supervisor Customer Service Rep. __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ DISPOSITIONS Liquor Board (Hearing files only) Letter Attached ___________________ Revoked-Order#___________________ Reverted-Order# __________________ Page 1 of 1 Intent to Halt Application Denied Application Withdrawn 9/11/2015 American LegalNet, Inc. #____________________ Individuals requiring ADA accommodations please call (602)542-9027