1025 Union Ave SE, Olympia, WA 98501-1539 PO Box 43085, Olympia, WA 98504-3085
(360) 664-1600 lcb.wa.gov
LIQ 1357 - 06/2020
Affidavit of Lost or Replacement Mixologist/Server Permit
Please print and complete the following information. Check the MAST Permit Checker
for your class date, permit expiration date, permit number, and more at:
https://lcb.wa.gov/mastrvp/mast-permit-checker
LOST PERMIT: ____ NAME CHANGE: ____ PERMIT NUMBER IF KNOWN:
DATE OF ORIGINAL CLASS: __________________ CERTIFIED FOR: CLASS 12: ___ CLASS 13:
Your name on the permit must match the name on the ID (such as driver’s license)
LAST NAME: ________________________________ FORMER NAME:
FIRST NAME: _____________________________________________ MIDDLE INITIAL:
SOCIAL SECURITY NUMBER: ___________________________ DATE OF BIRTH:
PRESENT MAILING ADDRESS:
CITY: ________________________________ STATE: ____________ ZIP + 4: ___________--
EMAIL ADDRESS: ____________________________________________________________________
SEX: M F X HEIGHT: _____ WEIGHT: _____ PHONE # :(______)
EMPLOYER: _____________________________________ PHONE # :(______)
I certify under penalty of perjury that all answers and statements are true, correct and
complete. I understand that untruthful or misleading answers are cause for rejection of my
application and/or revocation of any certification granted.
SIGNATURE: _____________________________________________ DATE: ___________________
Please mail the completed form and $5.00 check or Money Order to:
WSLCB, MAST Coordinator
PO Box 43085
Olympia, WA 98504-3085
Note: Per Agency Policy #565, customers who submit a returned check are required to pay a $30 fee and
must make full restitution within 30 calendar days. If a non-licensed customer does not make full
restitution of the returned check within 30 calendar days, the check shall be sent to a collection agency.
Make checks payable to WSLCB.
WSLCB Use Only
Receipt #: __________________
Expiration Date: _______________________________ Issued Permit #: ________________________
