Form AB-0201 "Request for Replacement Permit" - Tennessee

What Is Form AB-0201?

This is a legal form that was released by the Tennessee Alcoholic Beverage Commission - a government authority operating within Tennessee. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Tennessee Alcoholic Beverage Commission;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form AB-0201 by clicking the link below or browse more documents and templates provided by the Tennessee Alcoholic Beverage Commission.

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Download Form AB-0201 "Request for Replacement Permit" - Tennessee

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STAFF USE ONLY
PERMIT TYPE
______________________
ORIGINAL PERMIT
NUMBER
______________________
REQUEST FOR REPLACEMENT PERMIT
DATE ORIGINAL
PERMIT ISSUED
CASHIER’S CHECK OR MONEY ORDER ONLY
_____________________
REPLACEMENT PERMIT
$10.00 FEE NON-REFUNDABLE
NUMBER
Date
, 20
______________________
Name of Applicant
DATE REPLACEMENT
PERMIT PROCESSED
Home Street Address
_____________________
City
State
Zip
County
Telephone No. (
)
Email:
S. S. #
-
-
D. L. #
State Issued
Age
Date of Birth
Place of Birth
City
State
Sex
Race
1. List all names you have used including maiden name, nicknames, or any other names by which you have been
known.
2. Do you acknowledge that the sale or service of alcohol to a minor or intoxicated person can result in
disciplinary actions being taken against your permit?
WARNING:
YOUR STATEMENT IS MADE UNDER OATH OR AFFIRMATION. PROVIDING FALSE OR INCOMPLETE
INFORMATION IS GROUNDS FOR REJECTION OF APPLICATION OR SUSPENSION OR REVOCATION OF PERMIT IF
ISSUED. FALSE STATEMENTS OR INCOMPLETE INFORMATION ARE ALSO SUBJECT TO THE PENALTIES OF
PERJURY UNDER TENNESSEE LAW.
*THE ACCEPTANCE OF FEES DOES NOT GUARANTEE THE ISSUANCE OF A LICENSE OR PERMIT*
PRINT NAME
SIGNATURE
----------------------------------------------------------------------------------------------------------------------------- -------------------------------------
Subscribed and sworn to before me this
day of
20
My Commission Expires
Notary Public
TABC Validation
Notary Seal
The State of Tennessee and the Tennessee Alcoholic Beverage Commission are
Equal Opportunity Employers. Discrimination, in any of its practices, which is
based on age, race, sex, color, religion, national origin, disabling condition or any
other nonmerit factor is prohibited.
Thus, the Tennessee Alcoholic Beverage
Commission is an equal opportunity, equal access, affirmative action public entity.
FOR ADDITIONAL INFORMATION:
Contact the agency ADA Coordinator for this state agency: Assistant Director at
615-741-1602 or the Tennessee Office of Americans with Disabilities, Department
of Personnel. Alternate formats of this notice are available on request.
AB-0201
RDA 2114
1
STAFF USE ONLY
PERMIT TYPE
______________________
ORIGINAL PERMIT
NUMBER
______________________
REQUEST FOR REPLACEMENT PERMIT
DATE ORIGINAL
PERMIT ISSUED
CASHIER’S CHECK OR MONEY ORDER ONLY
_____________________
REPLACEMENT PERMIT
$10.00 FEE NON-REFUNDABLE
NUMBER
Date
, 20
______________________
Name of Applicant
DATE REPLACEMENT
PERMIT PROCESSED
Home Street Address
_____________________
City
State
Zip
County
Telephone No. (
)
Email:
S. S. #
-
-
D. L. #
State Issued
Age
Date of Birth
Place of Birth
City
State
Sex
Race
1. List all names you have used including maiden name, nicknames, or any other names by which you have been
known.
2. Do you acknowledge that the sale or service of alcohol to a minor or intoxicated person can result in
disciplinary actions being taken against your permit?
WARNING:
YOUR STATEMENT IS MADE UNDER OATH OR AFFIRMATION. PROVIDING FALSE OR INCOMPLETE
INFORMATION IS GROUNDS FOR REJECTION OF APPLICATION OR SUSPENSION OR REVOCATION OF PERMIT IF
ISSUED. FALSE STATEMENTS OR INCOMPLETE INFORMATION ARE ALSO SUBJECT TO THE PENALTIES OF
PERJURY UNDER TENNESSEE LAW.
*THE ACCEPTANCE OF FEES DOES NOT GUARANTEE THE ISSUANCE OF A LICENSE OR PERMIT*
PRINT NAME
SIGNATURE
----------------------------------------------------------------------------------------------------------------------------- -------------------------------------
Subscribed and sworn to before me this
day of
20
My Commission Expires
Notary Public
TABC Validation
Notary Seal
The State of Tennessee and the Tennessee Alcoholic Beverage Commission are
Equal Opportunity Employers. Discrimination, in any of its practices, which is
based on age, race, sex, color, religion, national origin, disabling condition or any
other nonmerit factor is prohibited.
Thus, the Tennessee Alcoholic Beverage
Commission is an equal opportunity, equal access, affirmative action public entity.
FOR ADDITIONAL INFORMATION:
Contact the agency ADA Coordinator for this state agency: Assistant Director at
615-741-1602 or the Tennessee Office of Americans with Disabilities, Department
of Personnel. Alternate formats of this notice are available on request.
AB-0201
RDA 2114
1