Cost: $15.00
Background Check Complete: ________ Date: _________
to Serve Fermented Malt Beverages and Intoxicating Liquors
License Year July 1, ____ through June 30, ____
Answer the following questions fully and completely:
Name of Applicant:_______________________________________________________
Driver’s License #: _______________________________________________________
I certify that I am _____ years of age. Date of Birth:_____/_____/_____
Address of Applicant______________________________________________________
Place of Employment:______________________________________________________
If renewal within the past 2 years, where was the privilege obtained?
As required by WI Statutes Section 125.17(6), have you completed the alcohol awareness
course?_______________ If so, where?_______________________________________
Have you been convicted of any felony or of violating any law of the State of Wisconsin or of
the United States?____________________________________________________________
Date of such conviction__________________ Name of court_______________________
Name of offense__________________________________________________________
Have you been convicted of violating any license law or ordinance regulating the sale of
Fermented malt beverages or intoxicating
Nature of violation________________________________________________________
I the undersigned, do hereby respectfully make application to the Town of Gibraltar, County
of Door, Wisconsin, for a License to serve, from date hereof to June 30,____, inclusive
(unless sooner revoked), Fermented Malt Beverages and Intoxicating Liquors, subject to the
limitations imposed by Section 125.32(2) and 125.68(2) of the Wisconsin Statutes and all acts
amendatory thereof and supplementary thereto, and hereby agree to comply with all laws,
resolutions, ordinances and regulations, Federal, State or Local, affecting the sale of such
beverages and liquors if a license be granted to me.
APPLICANT SIGNATURE: ___________________________ DATE: ______________
click to sign
click to edit