State of California Department of Alcoholic Beverage Control
LICENSE ACTION REQUEST
Read instructions on reverse before completing.
SECTION 1
1. LICENSEE'S NAME 2. LICENSE NUMBER
3. DOING BUSINESS AS (DBA) 4. DISTRICT OFFICE
5. PREMISES ADDRESS 6. LICENSE ATTACHED
Yes No
7. MAILING ADDRESS
SECTION 2 CANCELLATION
I voluntarily cancel my license because I am no longer in business. I understand my license cannot be reactivated or
reinstated.
8. CANCELLATION EFFECTIVE
Immediately Upon issuance of Other:
9. LICENSEE'S SIGNATURE 10. HOME PHONE NUMBER 11. DATE BUSINESS CLOSED 12. DATE SIGNED
( )
SECTION 3 SURRENDER - Rule 65
I voluntarily surrender my license for a period of not more than one year. I intend to Transfer Reactivate
the license. I understand that (a) the license must be renewed at the time renewal fees are due or the license will be automatically canceled;
(b) the Department will proceed to cancel my license after one year if not transferred or reactivated; and (c) I must report any change in my
mailing address to the Department.
13. SURRENDER EFFECTIVE
Immediately Upon issuance of Surrender by
Department
Premises abandoned
14. LICENSEE'S SIGNATURE 15. HOME PHONE NUMBER 16. DATE BUSINESS CLOSED 17. DATE SIGNED
( )
SECTION 4 SURRENDER OF PRIVILEGES FOR A SPECIAL EVENT
18. SPECIFIC ROOM OR AREA WHERE PRIVILEGES ARE TO BE SURRENDERED
19. DATE TO BE SURRENDERED 20. PERIOD OF SURRENDER (State starting and ending times) (type as X:XX xm)
to
21. LICENSEE'S SIGNATURE 22. HOME PHONE NUMBER
(
23. DATE SIGNED
SECTION 5 REQUEST FOR RETURN OF SURRENDERED LICENSE
I request the return of the surrendered license described above.
I declare under penalty of perjury that there has been no change in ownership of the licensed business, and the premises possess the same
qualifications required for the original issuance of the license.
24. LICENSEE'S SIGNATURE 25. HOME PHONE NUMBER 26. DATE LICENSE NEEDED 27. DATE SIGNED
( )
ABC USE ONLY
DATE LICENSE MAILED BY HEADQUARTERS
OR RETURNED BY DISTRICT OFFICE
Letter attached requesting surrender, cancellation or return
Accusation pending (Send copy of ABC-231 for cancellations to HQ H&L if accusation pending.)
Distribution:
Section 2: Original to HQ Lic; copy to District file Section 3: Original to HQ Lic; copy to District file; copy to suspense file
Section 4: Original to District file Section 5: Original + 1 copy to HQ Lic; copy to District file
ABC-231 (10/08)
)
