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Lawton Alcohol License Application - Retail Package Store

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Lawton Alcohol License Application - Retail Package Store Powered By Docstoc
					                                       COMMUNITY SERVICES DEPARTMENT
                                          LICENSE & PERMIT CENTER / INSPECTION SERVICES
                                                  Address: 212 SW 9 th Street, Lawton, Oklahoma 73501
                                                      Phone (580) 581-3360 • Fax (580) 581-3479
                                                                www.cityof.lawton.ok.us


                                RETAIL PACKAGE STORE APPLICATION
NEW APPLICATION                                       RENEWAL                                      DATE:

                                                BUSINESS INFORMATION
Business Name:
Business Street Address:
Business Mailing Address:
City/State/Zip:                                                  Business Telephone No:
Legal Description of Property (Street Address Is NOT Acceptable)
Lot:             Block:          Addition:



                                        OWNER/CORPORATE INFORMATION
Business Owner’s Name*:                                                  Is Business a Corporation? YES          NO
Owner’s Address:                                                         Business Tax ID #:
City/State/Zip:                                                          Telephone No:
*List all names and social security numbers used in the preceding five (5) years of ALL individuals owning at least 10% interest in the
business. Additional sheets attached?        Yes      No
Owner’s Names:                                        Social Security Numbers:                     Driver’s License Numbers:




                                       APPLICANT/MANAGER INFORMATION
Applicant/Manager’s Name:                                               Relation To Business:
Home Address:                                                           Cell Phone No:
City/State/Zip:                                                         Home Telephone No:

I certify under penalty of perjury that the information contained on this application is true and correct. I further understand
that any incorrect information contained on this application may result in the revocation of any license issued and/or criminal
prosecution.

SIGNATURE OF APPLICANT: ____________________________________________________________


Subscribed and sworn to before me this _______ day of__________________________, 20___.

My Commission Expires: _______________________                 Notary Signature: ______________________________________

My Commission Number: _______________________




                                                                   1
                                      DEPARTMENTAL ACTION

ZONING INSPECTOR:          INSPECTION DATE: __________________________           APPROVAL   DENIAL

SIGNATURE: __________________________________________   REPORT ATTACHED?              YES      NO

FIRE MARSHAL:              INSPECTION DATE:__________________________            APPROVAL   DENIAL

SIGNATURE: __________________________________________   REPORT ATTACHED?              YES       NO

Comments:




                                   LICENSE AND PERMIT ACTION
APPROVED:                                         DENIED:
License No:                                             Denial Letter Date:
Receipt No:                                             Certified Mail Number:
Issue Date:                Expiration Date:             Appeal Time Expires:
License Clerk:                                          Supervisor Approval:

REV 01/12




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