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DBPR ABT-6028 Division of Alcoholic Beverages and Tobacco (MyFloridaLicense)

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Auth. 61A-5.056, FAC 1
DBPR ABT-6028 – Division of Alcoholic Beverages and Tobacco
Application for Retail Tobacco Products Dealer Permit
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
2601 Blair Stone Road
Tallahassee, FL 32399-0783
DBPR Form
ABT-6028
Revised 02/2013
If you have any questions or need assistance in completing this application, please contact the Division of Alcoholic
Beverages & Tobacco’s (AB&T) local district office. Please submit your completed application and required fee(s) to
your local district office. This application may be submitted by mail, through appointment, or it can be dropped off. A
District Office Address and Contact Information Sheet can be found on AB&T’s web site at the link provided below:
http://www.myflorida.com/dbpr/abt/district_offices/licensing.html
SECTION 1 - CHECK TRANSACTION REQUESTED
Transaction Type:
New Permit Change to Legal Entity
Change to Related Parties
Change of Business Name
(only in connection with above)
SECTION 2 - CHECK TYPE OF SALES
Vending Machine Sales
Over the Counter Sales
Internet Web Site Address
Mobile VIN #:
Pipes Only
SECTION 3 - APPLICANT INFORMATION
If the applicant is a corporation or other legal entity, enter the name and the document number as registered
with the Florida Department of State Division of Corporations on the line below.
FEIN Number
Business Telephone Number
E-Mail Address (Optional)
Full Name of Applicant: (This is the name the license(s) will be issued (in)
Department of State Document #
Business Mailing Address
City
State
Zip Code
Contact Person - This section is optional, see application instructions for details
Contact Person
Telephone Number
ext.
E-Mail Address (Optional)
Mailing Address (Street or P.O. Box)
City
State
Zip Code
ABT District Office Received / Date Stamp
Auth. 61A-5.056, FAC 2
Is there an alcoholic beverage license issued at this location?
Yes No
If yes, list alcoholic beverage license number:
Business Name (D/B/A)
Location Address (Street and Number)
City
County
State
FL
Zip Code
Is there an alcoholic beverage license issued at this location?
Yes No
If yes, list alcoholic beverage license number:
Business Name (D/B/A)
Location Address (Street and Number)
City
County
State
FL
Zip Code
Is there an alcoholic beverage license issued at this location?
Yes No
If yes, list alcoholic beverage license number:
Business Name (D/B/A)
Location Address (Street and Number)
City
County
State
FL
Zip Code
Is there an alcoholic beverage license issued at this location?
Yes No
If yes, list alcoholic beverage license number:
Business Name (D/B/A)
Location Address (Street and Number)
City
County
State
FL
Zip Code
(ATTACH ADDITIONAL SHEETS AS NECESSARY)
SECTION 4 - PERMIT INFORMATION
Note: If this application is for a change to an existing permit holder, please enter the permit number(s) in the space provided,
otherwise leave blank. If the application is for a new permit(s), all other information is required.
Full Name of Applicant
Is there an alcoholic beverage license issued at this location? Yes No
If yes, list alcoholic beverage license number:
Business Name (D/B/A)
Location Address (Street and Number)
City
County
State
FL
Zip Code
Auth. 61A-5.056, FAC 3
SECTION 5 – RELATED PARTY PERSONAL INFORMATION
This section must be completed for each person directly connected with the business, unless they
are a current licensee.
Full Name of Applicant
Full Name of Individual
1
.
Social Security Number*
Home Telephone Number
Date of Birth
Race
Sex
Height
Weight
Eye Color
Hair Color
2
.
Are you a U.S. citizen?
Yes No
If no, immigration card number or passport number:
Home Address (Street and Number)
3
.
City
State
Zip Code
4
.
Have you, as an individual or as a principal of an entity, had a permit
revoked?
Yes No
Permit Number
5
.
Have you ever been adjudicated as owing $500 or more in delinquent cigarette taxes?
Yes No
6
.
Have you ever been convicted of selling stolen or counterfeit cigarettes, receiving stolen cigarettes, or
being involved in the counterfeiting of cigarettes?
Yes No
7
.
Have you been convicted within the past 5 years of any offense against the cigarette laws of this state or
convicted in this state, any other state, or the United States during the past 5 years of any offense
designated as a felony by such state or the United States, or to a corporation, any of whose officers have
been so convicted. The term “convicted” shall include an adjudication of guilt on a plea of guilty or a plea
of nolo contendere, or the forfeiture of a bond when charged with a crime?
Yes No
8
.
Have you ever imported, or caused to be imported, into the United States any cigarette in violation of 19
U.S.C. s. 1681a?
Yes No
Auth. 61A-5.056, FAC 4
9
.
Have you imported, or caused to be imported, into the United States, or manufactured for sale or
distribution in the United States, any cigarette that does not fully comply with the Federal Cigarette
Labeling and Advertising Act (15 U.S.C. ss. 1331 et seq.)?
Yes No
If you answered yes to any of the above questions 4-9, provide the specifics on a separate sheet of
paper and a copy of the Arrest Disposition.
NOTARIZATION STATEMENT
“I swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791, 562.45 and
837.06, Florida Statutes, that I have fully disclosed any and all parties financially and or contractually
interested in this business and that the parties are disclosed in the Disclosure of Interested Parties of this
application. I further swear or affirm that the foregoing information is true and correct.”
STATE OF_____________________
COUNTY OF____________________ _______________________________________________
APPLICANT SIGNATURE
The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this ___________Day
of_______________, 20_____, By _______________________________________who is ( ) personally
(print name of person making statement)
known to me OR ( ) who produced ___________________________________________as identification.
_______________________________________________ Commission Expires: ___________________
Notary Public
(ATTACH ADDITIONAL COPIES AS NECESSARY)
*Social Security Number
Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless a Federal statute specifically
requires it or allows states to collect the number. In this instance, disclosure of social security numbers is mandatory
pursuant to Title 42 United States Code, Sections 653 and 654; and sections 409.2577, 409.2598, and 559.79,
Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title
IV-D child support agency to assure compliance with child support obligations. Social Security numbers must also be
recorded on all professional and occupational license applications and are used for licensee identification pursuant to
the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193,
Sec. 317. The State of Florida is authorized to collect the social security number of licensees pursuant to the Social
Security Act, 42 U.S.C. 405(c)(2)(C)(I). This information is used to identify licensees for tax administration purposes.
This information is used to identify licensees for tax administration purposes, and the division will redact the
information from any public records request.
Auth. 61A-5.056, FAC 5
SECTION 6 – DISCLOSURE OF INTERESTED PARTIES
Note: Failure to disclose an interest, direct or indirect, could result in denial, suspension and/or revocation of your license.
You MUST list all persons and entities in the entire ownership structure. To determine which of those persons
must submit fingerprints and a Related Party Personal Information sheet, see the fingerprint section in the
application instructions.
Full Name of Applicant
1. When applicable, complete the appropriate section below. Attach extra sheets if necessary.
Title/Position Name Stock %
CORPORATION– List all officers, directors, and stockholders
GENERAL PARTNERSHIP – List all general partners
LIMITED LIABILITY COMPANY – List all managers (member & non-member), directors, officers, and members
LIMITED PARTNERSHIP – List all general and limited partners.
LIMITED LIABILITY PARTNERSHIP – List all partners
OTHER INTERESTS
These
q
uestions must be answered about this business for ever
y
p
erson or entit
y
listed as the a
pp
licant
1. Are there any persons or entities not disclosed who derive revenue from the business? Yes No
2. Are there any persons or entities not disclosed that have the right to receive revenue
based on a contractual relationship related to the control of the sale of retail tobacco
p
roducts?
Yes No
3. Are there any persons or entities not disclosed who have a right to a percentage payment
from the
p
roceeds of the business
p
ursuant to the lease?
Yes No
4. Are there any persons or entities not disclosed who have guaranteed or co-signed a loan? Yes No
If you answered yes to any of the above questions, a copy of the agreement must be submitted with this
application.
Auth. 61A-5.056, FAC 6
SECTION 7 - AFFIDAVIT OF APPLICANT
NOTARIZATION REQUIRED
Full Name of Applicant
"I hereby swear or affirm that I am duly authorized to make this affidavit and, as such, I hereby swear or
affirm under penalty of perjury as provided for in Sections 559.791 and 837.06, Florida Statutes, that all of
the persons named in this application are not less that eighteen (18) years of age and are qualified for
issuance of a Retail Tobacco Products Dealer Permit. It is understood that when the permit is issued, the
place or premises covered by the permit is subject to inspection and search without a search warrant by the
division or its authorized employees, sheriffs, deputy sheriffs or police officers to determine compliance with
Chapter 210 and 569, Florida Statutes. I further swear or affirm the foregoing information is true and
correct."
STATE OF_____________________
COUNTY OF___________________
_________________________________________________
APPLICANT SIGNATURE
_________________________________________________
APPLICANT SIGNATURE
The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this ___________Day
of_______________, 20_____, By _______________________________________who is ( ) personally
(print name(s) of person(s) making statement)
known to me OR ( ) who produced ___________________________________________as identification.
________________________________________________ Commission Expires: ___________________
Notary Public
Auth. 61A-5.056, FAC 7
SECTION 8 - CURRENT PERMITTEE UPDATE DATA SHEET
This section is to be completed for all current retail tobacco product dealer permit holders listed on the
application to ensure the most up to date information is captured.
Full Name of Applicant
Last Name
First M.I.
Current Alcohol Beverage and/or Tobacco License Permit/Number(s)
Date of Birth
Social Security Number*
Street Address
City
State
Zip Code
Last Name
First M.I.
Current Alcohol Beverage and/or Tobacco License Permit/Number(s)
Date of Birth
Social Security Number*
Street Address
City
State
Zip Code
Last Name
First M.I.
Current Alcohol Beverage and/or Tobacco License Permit/Number(s)
Date of Birth
Social Security Number*
Street Address
City
State
Zip Code
Last Name
First M.I.
Current Alcohol Beverage and/or Tobacco License Permit/Number(s)
Date of Birth
Social Security Number*
Street Address
City
State
Zip Code
Last Name
First M.I.
Current Alcohol Beverage and/or Tobacco License Permit/Number(s)
Date of Birth
Social Security Number*
Street Address
City
State
Zip Code
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DBPR ABT-6028 Division of Alcoholic Beverages and Tobacco (MyFloridaLicense)

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Completed 22 February 2021

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