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L-D

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DIAGRAM FORM
FORM L-D (1/2020)
STATE OF TEXAS
COUNTY OF
BEFORE ME, the undersigned authority, on this day personally appeared
, credible person(s), and
Name of Applicant
who after being by me duly sworn did depose and say:
Applicant or applicants hereby certify that the diagram of the premises attached
at is a fair
Address
and accurate representation of the subject in question as it exists on the date of this
application and is a part of this application. I also certify that this diagram will be posted
with my license/permit.
Printed Name of Applicant
Signature of Applicant
AKNOWLEDGEMENT
Subscribed and sworn before me, this day of , 20 .
Signature of Notary
SEAL
DIAGRAM
FORM L-D (1/2020)
Approved by: Date:
Printed Name of TABC Employee
Signature of TABC Employee
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L-D

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Completed 18 July 2020

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