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Local ABT District Licensing Offices _ INSTRUCTIONS FOR (MyFloridaLicense)

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Auth. 61A-5.010 & 61A- 5.056, FAC 1
_
INSTRUCTIONS FOR COMPLETING
DBPR ABT– 6001
DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO
APPLICATION FOR NEW ALCOHOLIC BEVERAGE LICENSE
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:
Local ABT District Licensing Offices
GENERAL INSTRUCTIONS
Submitting Your Application
Applications for new alcoholic beverage licenses are filed with the Division of Alcoholic Beverages and Tobacco.
Please complete all information. All questions must be answered fully and truthfully. You must provide an
original application with original signatures. If you are required to submit any supporting documentation, such as
the items listed below, a copy of the document is acceptable. Once submitted, your application cannot be
returned to you. We will notify you in writing if your application has any errors or omissions and you will be given
the opportunity to submit the corrected or required document.
Note: When applicable, you must submit a legible and executed copy of the following: Right of Occupancy,
lease, or deed (must be in the name of the entity applying for the license), Franchise Agreement, Management
Contract, Concession Agreement, and any agreement which requires a percentage payment from the business
operation, Certified Copy of Death Certificate, Letters of Administration, Certificate of Title, Certified Copy of all
Court Orders pertaining to the alcoholic beverage license.
If eligible, a temporary license may be purchased. Permanent and temporary license fees may be found at
License Fee Chart & Temporary License Fee Chart
Contact Person
All communications regarding your application and invoices for payments of initial and renewal fees will be sent
to the applicant/licensee at the mailing or email address provided. However, if you would like for us to
communicate with someone other than the applicant regarding your application, please provide the name and
contact information for that person in the “License Information” section. Your named contact person will be
permitted to make changes to the application paperwork on your behalf (except Related Party Personal
Information Sheet) and we will communicate directly with them regarding any application issues or deficiencies,
and you will not be copied by the division with the correspondence. Once the application is approved, all
invoices and any subsequent communications will be sent to the mailing address of the licensee.
APPLICATION REQUIREMENTS AND INSTRUCTIONS FOR COMPLETING THIS APPLICATION
License Types
Refer to the “Alcoholic Beverages and Tobacco” page on the Department of Business and Professional
Regulation’s Internet site for the License Type data chart. This is provided to guide applicants in knowing how
each license type is defined in order to clarify which license type suits their needs.
Types of Licenses and Permits
Zoning Approval
Zoning approval is executed by the city or county zoning authority in which the business to be licensed is
located. Zoning approval is required on all new and change of location applications unless the applicant is a
state college or university located on State owned property. Zoning approval may also be required
for certain change or increase in series applications. Zoning approval is not required on new applications for
1APS licenses unless required pursuant to a Special Act for the county in which you are applying. This
information can be found at Local Zoning Departments
Auth. 61A-5.010 & 61A- 5.056, FAC 2
Department of Revenue Clearance
Department of Revenue clearance is required on applications for all new, transfer, change of location, and
applications which change the licensee’s name. The address for the office serving your area of interest can be
found at Local ABT District Licensing Offices.
Health Approval
Health approval is required on all applications for consumption on the premises. Businesses that serve food or
are located on premises licensed by the Division of Hotels and Restaurants, must obtain approval from that
division. Businesses that do not serve food must contact the County Health Authority or the Department of
Health. Food service establishments located in grocery and convenience stores, bakeries or delicatessens must
contact the Department of Agriculture and Consumer Services. The address for the office serving your area of
interest can be found at Local ABT District Licensing Offices.
Affidavit of Applicant
Read and sign in the presence of a notary. The affidavit must be signed by the individual applicant, each partner
of a general partnership, a general partner of a general partnership of a limited partnership, a managing
member, manager, or officer of a limited liability company, each partner of a limited liability partnership, or one of
the officers of a corporate applicant.
Fingerprints
Note: If you are a current licensee with the Florida Division of Alcoholic Beverages & Tobacco you are not
required to submit a new set of fingerprints with your application unless you have been arrested since your prior
submission of fingerprints to the division. If you are not a current licensee but have been fingerprinted for this
division in the past three (3) years, and you have not been arrested since that time, you are not required to submit
new fingerprints unless the prior application was withdrawn or non-consummated. Applicants whose fingerprints
are returned to the division as illegible will be required to submit a second set of fingerprints.
Fingerprints must be submitted by each sole proprietor; officers, directors, individual share holders
owning more than ½ of 1 percent of stock in non-public corporations; general partners of general
partnerships; general partners of a limited partnership; officers, managing members or managers of a
limited liability company; partners of a limited liability partnership, and persons directly interested and
receiving financial proceeds from the business.
Applicants must use a Livescan vendor that has been approved by the Florida Department of Law Enforcement to
submit their fingerprints to the department. Costs associated with the fingerprint process will be collected by the
vendor. Vendor options and contact information can be viewed at Livescan Device Vendors List (Livescan Device
Vendors List). Please ensure that the Originating Agency Identification (ORI) number for the Division of Alcoholic
Beverages and Tobacco is provided to the vendor when you submit your fingerprints. The ORI number is
FL920150Z. If you do not provide the ORI number, or if you provide an incorrect ORI number to the vendor, the
Department of Business and Professional Regulation will not receive your fingerprint results.
Out of State Alcoholic Beverage and Tobacco Applicants only:
Your fingerprint card can be obtained from the Department of Business and Professional Regulation by
contacting the Division of Alcoholic Beverages and Tobacco at 850.488.8284, or one of the division’s district
offices. A listing of the district offices on the web can be found at
Local ABT District Licensing Offices
OUT OF STATE LIVESCAN FINGERPRINTING REGISTRATION DIRECTIONS:
1. Go to the FDLE Livescan Device Vendors List and choose a Livescan vendor that is certified as “hard card
scanning capable”. These vendors have the ability to process fingerprints through additional methods,
including the use of hard copy fingerprint cards. If the vendor requests that you provide a fingerprint card,
you may call the Department of Business and Professional Regulation at 850.487.1395 to obtain one. When
requesting a card, please specify the profession for which you are seeking licensure.
2. If you are unable to obtain fingerprinting services through an FDLE approved “hard card scanning capable”
vendor, please contact the Department of Business and Professional Regulation by calling 850.487.1395 to
request the alternative procedure for fingerprint processing and fingerprint card. Each fingerprint card has a
specific ORI code identifying the profession. When requesting a card, please specify the profession for which
you are seeking licensure. Once the fingerprint card is received, you may then go to a local law enforcement
office in your area to have your fingerprints rolled onto the card. Other information will be completed at the
local law enforcement agency. For all programs, the completed card must be mailed to: FLDBPR, Florida
Auth. 61A-5.010 & 61A- 5.056, FAC 3
Fingerprinting Program, Prints Inc., 119 East Park Avenue, Tallahassee, FL 32301, where the
fingerprint card will be scanned. Prior to mailing your fingerprint card, you must complete the steps listed at
https://pearson.ibtfingerprint.com/ in order to register and make an advance payment of $50.00 plus Florida
Sales Tax. Do not send any money to Prints Inc. Out of State Alcoholic Beverage and Tobacco Applicants
only: Your fingerprint card can be obtained from the Department of Business and Professional Regulation by
contacting the Division of Alcoholic Beverages and Tobacco at 850.488.8284, or one of the division’s district
offices. A listing of the district offices can be found here.. Once the fingerprint card is received, you may then
go to a local law enforcement officer in your area to have your fingerprints rolled onto the card. Information
specific to the Division of Alcoholic Beverages and Tobacco will be preprinted on the fingerprint card. Other
information will be completed at the local law enforcement agency. The instructions for submitting your
fingerprint card are outlined above.
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, and the division will
redact the information from any public records request.
Directly/Indirectly Interested Person
A direct interest is created by a person or entity having an interest with the applicant in the business sought to be
licensed and, includes but is not limited to:
1. an interest which is created by virtue of the interested party deriving revenue from the sale of alcoholic
beverages;
2. a person or entity having the right to receive revenue based on a contractual relationship related to the control
of the sale of alcoholic beverages, the terms of which, are contrary to 561.17, Florida Statutes, or 61A-3.017,
Florida Administrative Code;
3. a person or entity who has a right to a percentage payment from the proceeds of the business pursuant to a
lease;
4. a guarantor on a lease or loan;
5. a co-signer on a lease or loan.
An indirect interest includes, but is not limited to, any person or entity that derives revenue from the license
solely through a contractual relationship with the licensee, the substance of which is not related to the control of
the sale of alcoholic beverages, or is specifically exempt by statute or rule.
Note: Direct and indirect interests must be disclosed in the “DISCLOSURE OF INTERESTED PARTIES” section
of the application.
Registration of Legal Entity
All corporations, domestic or foreign; general partnerships; limited liability companies; limited liability
partnerships; and limited partnerships are required to be registered with the Florida Department of State, Division
of Corporations. If you have not already registered, you will need to contact the Department of State at (850)
488-9000 or www.sunbiz.org for further information. Your application will be considered incomplete without this
active registration.
Related Party Personal Information
This section of the application must be completed by each applicant or person(s) directly connected with the
business, unless they are a current licensee. The signature of each person filling out this section of the
application must be an original. This will include the sole proprietor, all partners, officers, directors, individual
share holders owning more than ½ of 1 percent of stock in non-public corporations, all partners of each general
partnership, all general partners of a limited partnership, all managing members or managers of a limited liability
company, partners of a limited liability partnership, and persons directly interested and receiving financial
proceeds from the business. It is important that each individual discloses any arrests they have had within the
past 15 years, even if they were charged, but not formally arrested, and regardless of the disposition.
Auth. 61A-5.010 & 61A- 5.056, FAC 4
Copy of Arrest Disposition
If the applicant answers “yes” to any of the criminal background questions asked in this application, provide a
copy of the Arrest Disposition to ensure the applicant is qualified, pursuant to Statute and Rule.
Applicable Statutes and Rule: 561.15 & 561.17, Florida Statutes; and 61A-1.017, Florida Administrative Code.
Moral Character
The applicant is required to meet the moral character standards to have an interest in an alcoholic beverage
license. Any person failing to meet those standards shall be required to submit mitigation under the moral
character rule in order for the division to determine if the person is qualified. A copy of the rule and requirements
can be found at Moral Character.
Federal Employer's Identification Number (FEIN)
All licensees who pay wages to one or more employees must have a Federal Employer's Identification Number.
Contact the Internal Revenue Service (IRS) at 1-800-829-3676 and request Form #SS4.
Surety Bond
Surety bonds are required on all new applications for manufacturers, wholesale distributors of alcoholic
beverages, wholesale distributors of cigarettes, and other tobacco products. A surety bond or a rider to the
original bond must be submitted on any change of business name, change of location or change of ownership
name application by the aforementioned. You may wish to have an auditor review your surety bond prior to
submitting this application. Contact the division's Auditing Office serving your area of interest for further
information. A list of the Auditing offices can be found at Audit District Offices
Sketch of Premises
A complete sketch of the premises, drawn in ink or computer generated (letter size) which includes all permanent
walls, doors, windows, counters, labeling each room and area. Include any outside areas where alcoholic
beverages will be sold, consumed, or served. Due to the difficulty of scanning, no blueprints are accepted.
APPLICATION CHECKLIST
TRANSACTION
APPLICATION REQUIREMENTS
New License
Complete DBPR ABT-6001 Division of Alcoholic Beverages and
Tobacco Application for New Alcoholic Beverage License
Pay $100 or ¼ of the annual license fee, whichever is greater, if
requesting a temporary license (make check payable to the Division
of Alcoholic Beverages and Tobacco)
Submit Fingerprint receipt, if applicable
Submit a copy of Arrest Disposition, if applicable
Submit Mitigation for Moral Character, if applicable
Manufacturers and wholesale distributors of alcoholic beverages
must complete and submit the DBPR ABT-6032 Surety Bond form
Submit Right of Occupancy
Application may also include
New Retail Tobacco Products Dealer Permit
Auth. 61A-5.010 & 61A- 5.056, FAC 1
DBPR ABT-6001 – Division of Alcoholic Beverages and Tobacco
Application for New Alcoholic Beverage License
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
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:
Local ABT District Licensing Offices
SECTION 2 – LICENSE 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(s): (This is the name the license will be issued in)
Department of State Document #
Business Name (D/B/A)
Location Address (Street and Number)
City
.
.
County
State
FL
Zip Code
Mailing Address (Street or P.O. Box)
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
SECTION 1 - CHECK LICENSE CATEGORY
License Series Requested
Type/Class Requested
Do you wish to purchase a Temporary License?
Yes No
Child License Requested
Number of Child Licenses Requested
Retail Alcoholic Beverages
Beer/Wine/Liquor Wholesaler
Alcoholic Beverage Manufacturer
Passenger Waiting Lounge
Retail Tobacco Products Dealer Permit (must check one or more of the below)
Pipes Over the Counter Vending Machine
Auth. 61A-1.023 & 61A-5.056, FAC 2
ABT District Office Received Date Stamp
SECTION 3 – RELATED PARTY PERSONAL INFORMATION
This section must be completed for each person directly connected with the business, unless they
are a current licensee.
1.
Business Name (D/B/A)
2.
Full Name of Individual
Social Security Number*
Home Telephone Number
Date of Birth
Race
Sex
Height
Weight
Eye Color
Hair Color
3.
Are you a U.S. citizen?
Yes No
If no, immigration card number or passport number:
4.
Home Address (Street and Number)
City
State
Zip Code
5.
Do you currently own or have an interest in any business selling alcoholic beverages, wholesale
cigarette or tobacco products, or a bottle club?
Yes No
If yes, provide the information requested below. The location address should include the city and state.
Business Name (D/B/A)
License Number
Location Address
6.
Have you had any type of alcoholic beverage, or bottle club license, or cigarette, or tobacco permit
refused, revoked or suspended anywhere in the past 15 years?
Yes No
If yes, provide the information requested below. The location address should include the city and state.
Business Name (D/B/A)
Date
Location Address
7.
Have you been convicted of a felony within the past 15 years? Yes No
If yes, provide the information requested below and provide a Copy of the Arrest Disposition, as
requested in the Application Requirements checklist.
Date
Location
Type of Offense
8.
Have you been convicted of an offense involving alcoholic beverages or tobacco products anywhere
within the past 5 years? Yes No
If yes, provide the information requested below and provide a Copy of the Arrest Disposition, as
requested in the Application Requirements checklist.
Date
Location
Type of Offense
Auth. 61A-5.010 & 61A-5.056, FAC 2
9.
Have you been arrested or issued a notice to appear in any state of the United States or its territories
within the past 15 years? Yes No
If yes, provide the information requested below and a Copy of the Arrest Disposition.
Attach additional sheet if necessary.
Date
Location
Type of Offense
10.
Do you meet the standards of the moral character rule?
Yes No
11.
Are you an officer or employee of the Division of Alcoholic Beverages and Tobacco; are you a sheriff or
other state, county, or municipal officer, including reserve or auxiliary officers, certified by the state as
such, with arrest powers, whose certification is current and active?
Yes No
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.
click to sign
signature
click to edit
Auth. 61A-5.010 & 61A-5.056, FAC 3
SECTION 4 – DESCRIPTION OF PREMISES TO BE LICENSED
TO BE COMPLETED BY THE APPLICANT
Business Name (D/B/A)
1.
Yes
No
Is the proposed premises movable or able to be moved?
2.
Yes
No
Is there any access through the premises to any area over which you do not have
dominion and control?
3.
Yes
No
Is the business located within a Specialty Center? If yes, check the applicable statute:
561.20(2)(b)1, F.S. or 561.20(2)(b)2, F.S.
4.
Yes
No
Are there any mobile vehicles used to sell or serve alcoholic beverages?
5.
Yes
No
Are there more than 3 separate rooms or enclosures with permanent bars or
counters?
Neatly draw a floor plan of the premises in ink, including sidewalks and other outside areas which are contiguous to the
premises, walls, doors, counters, sales areas, storage areas, restrooms, bar locations and any other specific areas which
are part of the premises sought to be licensed. A multi-story building where the entire building is to be licensed must
show the details of each floor.
Auth. 61A-5.010 & 61A-5.056, FAC 4
SECTION 5 – APPLICATION APPROVALS
Full Name of Applicant: (This is the name the license will be issued in)
Business Name (D/B/A)
Street Address
City
.
.
County
State
FL
Zip Code
ZONING
TO BE COMPLETED BY THE ZONING AUTHORITY GOVERNING YOUR BUSINESS LOCATION
A. The location complies with zoning requirements for the sale of alcoholic beverages or wholesale
tobacco products pursuant to this application for a Series: Type: license.
B. This approval includes outside areas which are contiguous to the premises which are to be part of the
premises sought to be licensed and are identified on the sketch?” Yes No
Check either: Please do not skip, this is important for license fee sharing
Location is within the city limits or Location is in the unincorporated county
Signed____________________________________________________Date__________________
Title_________________________________________ This approval is valid for ______ days.
SALES TAX
TO BE COMPLETED BY THE DEPARTMENT OF REVENUE
The named applicant for a license/permit has complied with the Florida Statutes concerning registration for
Sales and Use Tax.
1. This is to verify that the current owner as named in this application has filed all returns and that all
outstanding billings and returns appear to have been paid through the period ending _______________
or the liability has been acknowledged and agreed to be paid by the applicant. This verification does not
constitute a certificate as contained in Section 213.758 (4), F.S. (Not applicable if no transfer involved).
2. Furthermore, the named applicant for an Alcoholic Beverage License has complied with Florida Statutes
concerning registration for Sales and Use Tax, and has paid any applicable taxes due.
Signed____________________________________________________Date_____________________
Title____________________________________________ Department of Revenue Stamp
This approval is valid for _______ days.
HEALTH
TO BE COMPLETED BY THE DIVISION OF HOTELS AND RESTAURANTS
OR COUNTY HEALTH AUTHORITY
OR DEPARTMENT OF HEALTH
OR DEPARTMENT OF AGRICULTURE & CONSUMER SERVICES
The above establishment complies with the requirements of the Florida Sanitary Code.
Signed_______________________________________________________Date____________________
Title________________________________________________ Agency____________________________
This approval is valid for _______ days.
Auth. 61A-5.010 & 61A-5.056, FAC 5
SECTION 7 – SPECIAL LICENSE REQUIREMENTS
(DOES NOT APPLY TO BEER AND WINE LICENSES)
Please check the appropriate box of the license for which you are applying. Fill in the corresponding
requirements for the license type sought.
Quota Alcoholic Beverage License Specialty Alcoholic Beverage License (e.g. SRX, S, etc)
Club Alcoholic Beverage License
This license is issued pursuant to , Florida Statutes or Special Act, and as such we
acknowledge the following requirements must be met and maintained:
Please initial and date:
Applicant’s Initials____________________________________ Date______________________________
SECTION 6 – APPLICANT ENTITY FELONY CONVICTION
Business Name (D/B/A)
Has the applicant entity been convicted of a felony in this state, any other state, or by the United States in
the last 15 years?
Yes No
If the answer is “Yes,” please list all details including the date of conviction, the crime for which the entity
was convicted, and the city, county, state and court where the conviction took place.
(Attach additional sheets if necessary)
Auth. 61A-5.010 & 61A-5.056, FAC 6
SECTION 8 – 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.
Business Name (D/B/A)
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
Bar Manager (Fraternal Organizations of National Scope only):
OTHER INTERESTS
These questions must be answered about this business for every person or entity listed as the applicant
1. Are there any persons or entities not disclosed who have loaned money to the business?
Yes No
2. Are there any persons or entities not disclosed that derive revenue from the license solely
through a contractual relationship with the licensee, the substance of which is not related to the
control of the sale of alcoholic beverages, or is exempt by statute or rule?
Yes No
3. 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 alcoholic beverages?
Yes No
4. Are there any persons or entities not disclosed who have a right to a percentage payment from
the proceeds of the business pursuant to the lease?
Yes No
5. Are there any persons or entities not disclosed who have guaranteed the lease or loan?
Yes No
6. Are there any persons or entities not disclosed who have co-signed the lease or loan?
Yes No
7. Is there a management contract, franchise agreement, or concession agreement in connection
with this business?
Yes No
8. Have you or anyone listed on this application, accepted money, equipment or anything of
value in connection with this business from any industry member as described in 61A-1.010,
Florida Administrative Code?
Yes No
If you answered yes to any of the above questions, a copy of the agreement must be submitted with this
application. The terms of the agreement may require the interested persons or parties related to an entity to
submit fingerprints and a related party personal information sheet.
Auth. 61A-5.010 & 61A-5.056, FAC 7
SECTION 9 - AFFIDAVIT OF APPLICANT
NOTARIZATION REQUIRED
Business Name (D/B/A)
“I, the undersigned individually, or on behalf of a legal entity, hereby swear or affirm that I am duly authorized to
make the above and foregoing application and, as such, I hereby swear or affirm that the attached sketch is a
true and correct representation of the entire area and premises to be licensed and agree that the place of
business, if licensed, may be inspected and searched during business hours or at any time business is being
conducted on the premises without a search warrant by officers of the Division of Alcoholic Beverages and
Tobacco, the Sheriff, his Deputies, and Police Officers for the purposes of determining compliance with the
beverage and retail tobacco laws.”
“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 the foregoing information is true and that no other person or entity except as
indicated herein has an interest in the alcoholic beverage license and/or tobacco permit, and all of the above
listed persons or entities meet the qualifications necessary to hold an interest in the alcoholic beverage license
and/or tobacco permit.”
STATE OF________________________
COUNTY OF______________________
_________________________________________________
APPLICANT/AUTHORIZED REPRESENTATIVE NAME
_________________________________________________
APPLICANT /AUTHORIZED REPRESENTATIVE 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-5.010 & 61A-5.056, FAC 8
SECTION 10 - CURRENT LICENSEE UPDATE DATA SHEET
This section is to be completed for all current alcoholic beverage and/or tobacco license holders listed on the
application to ensure the most up to date information is captured.
Business Name (D/B/A)
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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Local ABT District Licensing Offices _ INSTRUCTIONS FOR (MyFloridaLicense)

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Completed 13 September 2021

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