Department of Alcoholic Beverage Control
State of California
This form is to be used for certain changes that need to be made to the licensee's information. It is used for most
of the miscellaneous license reporting requirements where an application is not required, including:
• Reporting corrections to license information such as a change in DBA (doing business as) or entity name
change
• Reporting a change of mailing address
Instructions: Complete items as appropriate. Items # 1, 4, 5, 7, 9 should be the licensee's
current information before the chang
e. When this form is completed, it must be submitted
to the District office.
1. LICENSE NUMBER
2. RECEIPT NUMBER
3.
FEE PAID
4.
LICENSEE'S NAME 5.
DOING
BUSINESS AS (DBA) 6.
DATE
7.
PREMISES ADDRESS (Street
number and
name,
city,
zip
code) 8.
DISTRICT
OFFICE
9.
MAILING
ADDRESS (Street
number and
name,
city,
state,
zip
code) 10.
LICENSEE'S PHONE NUMBER
11.
TYPE OF
PENDING
APPLICATION 12.
DATE APPLICATION
FILED 13.
ABIS UPDATED UPDATED BY
(INITIALS)
Yes No ________
14.
DOCUMENT
EXPLAINING
CHANGE ATTACHED
Yes No
15.
ACTION OR CHANGE
Name Change (Attach official document; e.g., certificate from Secretary of State, court order, marriage certificate)
DBA Change (Attach letter, if any, from licensee)
c.
Premises Address Change by City or County (Attach letter from city or county)
d.
Mailing Address Change
e.
Replacement of License Certificate (This is a non-refundable fee)
Other
f.
16. DETAILS OF CHANGE (e.g., annexation into city, fee for Code 8, etc.)
17.
RECOMMENDATION (Required for
Items 15a-c only) LICENSING REPRESENTATIVE SIGNATURE
DATE SIGNED
18. RECOMMENDATION (Required for Items 15a-c only) SUPERVISOR'S SIGNATURE DATE SIGNED
Distribution: Original to HQ Licensing (If replacement of license certificate, original to HQ Cashier with Transmittal);
ABC-219 (rev. 07/19)
