Formation

Type Of Business:

Will you be selling tobacco at this location:

Yes

No

FEIN #:

Business Phone #:

Email you would all license correspondence sent to:

Confirm Email you would all license correspondence sent to:

Corporate Name:

DBA / fictitious name:

Location Address

Number & Street:

Suite:

City:

State:

County:

Zip:

Mailing Address

Number & Street:

Suite:

City:

State:

Zip:

Officers Of Entity, Enter Each Officers Name And Phone Number

List Primary Officer Name Who Will Be Signing Documents:

Primary Officer Phone:

Primary Officer Owner Address Number & Street:

Primary Officer Suite:

Primary Officer City:

Primary Officer State:

Primary Officer County:

Primary Officer Zip:

Are you currently operating on an active alcohol or tobacco license in Florida?:

Yes

No

Are there any additional officers registered with the Florida Secretary of State?:

Yes

No

List Secondary Officer Name Who Will Be Signing Documents:

Secondary Officer Phone:

Secondary Officer Owner Address Number & Street:

Secondary Officer Suite:

Secondary Officer City:

Secondary Officer State:

Secondary Officer County:

Secondary Officer Zip:

Are there any additional officers registered with the Florida Secretary of State?:

Yes

No

List Third Officer Name Who Will Be Signing Documents:

Third Officer Phone:

Third Officer Owner Address Number & Street:

Third Officer Suite:

Third Officer City:

Third Officer State:

Third Officer County:

Third Officer Zip:

Are there outside areas where alcohol will be consumed?:

Yes

No

Has the applicant entity been convicted of a felony in this state, or any other state, or by the united states in the last 15 years?:

Yes

No