/s/
SECTION B
:
Complete this section to Cancel Issued Permit Class(es)
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 the
documents cannot be returned to the Division.
SECTION C: A Signature and Mailing Address are required in order to process your cancellation and/or submit a refund, if
applicable, to the appropriate address.
Print Name:
Telephone Number:
Mailing Address:
Permit Name:
Date:
Permit Address:
Permit City:
Permit State:
Permit ZIP Code:
Skip
"
Section B," and complete
"
Section C
"
below.
Pursuant to Ohio Administrative Code 4301:1-1-15, I hereby request the Division of Liquor Control cancel, without
refund, the issued permit number and class(es) captioned above.
Re:
Permit Number:
Zip Code:
State:
City:
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):
(Date)
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):
By typing your name, you accept your eSignature as your legal signature.
(Date)
:
(Signature of Permit Holder):
By typing your name, you accept your eSignature as your legal signature.
/s/
Cancellation Request
FOR OFFICE USE ONLY:
Permit # _____________________
New
Transfer
Ren
614 | 644 3155
Fax 614 | 644 3166
TTY/TDD 800 | 750 0750
www.com.ohio.gov
An Equal Opportunity Employer and Service Provider
6606 Tussing Road
PO Box 4005
Reynoldsburg, OH 43068-9005 U.S.A.
LIQ-19-0004
Rev. 5/8/2019
click to sign
signature
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signature
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