File with the Office of the City Secretary
2000 Forest Ridge Drive
Bedford, TX 76021
CITY OF BEDFORD
APPLICATION FOR ALCOHOLIC BEVERAGE
REGISTRATION FORM
NAME OF BUSINESS:
ADDRESS:
APPLICANT:
ADDRESS:
DATE:
REGISTRATION TYPE
Off-Premise Wine & Beer Retailer (BQ)
On-Premise Beer Retailer (BG)
Mixed Beverage (MB)
Mixed Beverage Late Hour (LB)
Initial Registration
Annual Registration Renewal*
LICENSING/REGISTRATION
INFORMATION SHOULD BE ADDRESSED TO:
Business Name:
Contact Person:
Address:
City: Zip:State:
ANNUAL GROSS SALES AFFIDAVIT*
INFORMATION SHOULD BE ADDRESSED TO:
Zip:State:City:
Address:
Contact Person:
Business Name:
To be completed by the City
Date Received: __________ By:____________________________
Distance previously approved per Section 109.59 of TABC?________
Signature ________________________________ Date: ___________
(If no, complete next Section)
Permitted Zoning: ________________________
Distance Map Attached: ___________________
_______________________________ Date: ___________
(Planning and Community Development Director)
* For On-Premise/Mixed Beverage establishments only
I, the undersigned, __________________________________, hereby certify that the information contained herein is true and correct.
__________________________________________ _________________________________________
Licensee/Agent Signature Title
BUSINESS
TELEPHONE:
APPLICANT
TELEPHONE:
Other:
Telephone: Telephone:
E-mail: E-mail:
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