"File Deactivation Form" - Arizona

This ""file Deactivation Form" - Arizona" is a part of the paperwork released by the Arizona Department of Liquor Licenses and Control specifically for Arizona residents.

The latest fillable version of the document was released on September 11, 2015 and can be downloaded through the link below or found through the department's forms library.

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Download "File Deactivation Form" - Arizona

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DLLC USE ONLY
Arizona Department of Liquor Licenses and Control
800 W Washington 5th Floor
Date:
Phoenix, AZ 85007-2934
www.azliquor.gov
Processed by:
(602) 542-5141
FILE DEACTIVATION FORM
Print and use black ink only
1.
TYPE OF ACTION:
LICENSE SURRENDER
APPLICATION WITHDRAWAL
2.
LICENSE DATA:
LICENSE NUMBER: _____________________________________
CONTROLLING PERSON / AGENT NAME: ______________________________________________________________________________
BUSINESS LOCATION NAME: _________________________________________________________________________________________
BUSINESS LOCATION ADDRESS: ______________________________________________________________________________________
MAILING ADDRESS: _________________________________________________________________________________________________
REASON FOR WITHDRAWAL/SURRENDER
________________________________________________________________________________________________________
________________________________________________________________________________________________________
USE BACK OF PAGE IF NECESSARY
I,
, hereby declare that I am a CONTROLLING PERSON and/or
(Print Full Name)
AGENT filing this notification. I have read this document and the contents and all statements are true, correct and complete.
X (Signature) ______________________________________________
State of ____________________County of ____________________
Controlling Person / Agent
The foregoing instrument was acknowledged before me this
My commission expires on: _______________________
____________ of ______________________ ____________
Day
Month
Year
__________________________________________________
FOR DLLC USE ONLY
Signature NOTARY PUBLIC
INVESTIGATIVE REVIEW
Requires Director or Designate and Chief of Investigations
DEPARTMENT PROTEST
or Designate approvals
DIRECTOR APPROVAL
YES
NO _________________________________________
CHIEF OF INVESTIGATIONS APPROVAL
YES
NO _________________________________________
REVIEW
EMPLOYEE
DATE
Received by
__________________________________
__________________
Background Investigator
__________________________________
__________________
(pending app.’s only)
Licensing Supervisor
__________________________________
__________________
Customer Service Rep.
__________________________________
__________________
Liquor Board
__________________________________
__________________
(Hearing files only)
DISPOSITIONS
Letter Attached ___________________
Intent to Halt
Revoked-Order#___________________
Application Denied
#____________________
Reverted-Order# __________________
Application Withdrawn
Page 1 of 1
9/11/2015
Individuals requiring ADA accommodations please call (602)542-9027
DLLC USE ONLY
Arizona Department of Liquor Licenses and Control
800 W Washington 5th Floor
Date:
Phoenix, AZ 85007-2934
www.azliquor.gov
Processed by:
(602) 542-5141
FILE DEACTIVATION FORM
Print and use black ink only
1.
TYPE OF ACTION:
LICENSE SURRENDER
APPLICATION WITHDRAWAL
2.
LICENSE DATA:
LICENSE NUMBER: _____________________________________
CONTROLLING PERSON / AGENT NAME: ______________________________________________________________________________
BUSINESS LOCATION NAME: _________________________________________________________________________________________
BUSINESS LOCATION ADDRESS: ______________________________________________________________________________________
MAILING ADDRESS: _________________________________________________________________________________________________
REASON FOR WITHDRAWAL/SURRENDER
________________________________________________________________________________________________________
________________________________________________________________________________________________________
USE BACK OF PAGE IF NECESSARY
I,
, hereby declare that I am a CONTROLLING PERSON and/or
(Print Full Name)
AGENT filing this notification. I have read this document and the contents and all statements are true, correct and complete.
X (Signature) ______________________________________________
State of ____________________County of ____________________
Controlling Person / Agent
The foregoing instrument was acknowledged before me this
My commission expires on: _______________________
____________ of ______________________ ____________
Day
Month
Year
__________________________________________________
FOR DLLC USE ONLY
Signature NOTARY PUBLIC
INVESTIGATIVE REVIEW
Requires Director or Designate and Chief of Investigations
DEPARTMENT PROTEST
or Designate approvals
DIRECTOR APPROVAL
YES
NO _________________________________________
CHIEF OF INVESTIGATIONS APPROVAL
YES
NO _________________________________________
REVIEW
EMPLOYEE
DATE
Received by
__________________________________
__________________
Background Investigator
__________________________________
__________________
(pending app.’s only)
Licensing Supervisor
__________________________________
__________________
Customer Service Rep.
__________________________________
__________________
Liquor Board
__________________________________
__________________
(Hearing files only)
DISPOSITIONS
Letter Attached ___________________
Intent to Halt
Revoked-Order#___________________
Application Denied
#____________________
Reverted-Order# __________________
Application Withdrawn
Page 1 of 1
9/11/2015
Individuals requiring ADA accommodations please call (602)542-9027
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