Dbpr Abt 6004 Form – Fill Out and Use This PDF

Check the Transaction Type requested: Change to Related Parties, Amendment to Licensed Entity Name, Conversion or Merger, or Change of Mailing Address.

If this application is being made as a result of a merger, the Division's licensee of record for the affected license(s) must have been the surviving entity. If the surviving entity is not the Division's licensee of record, a transfer of the license is required and you cannot use this form. If a transfer is required, go to Renew & Manage My License and complete the Application for Transfer of Ownership ABT-6002.

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.

Business Telephone Number. E-Mail Address (Optional). Department of State Document #. Mailing Address (Street or P.O. Box), City. Current Name of Licensee is the owner name the license(s) is currently issued in. Full Name of Applicant is the owner name the license will be issued in.

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.

If you would like the division to communicate with someone other than the applicant regarding your application, 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 you will not be copied by the division with the correspondence. Contact Person: Telephone Number ext.; E-Mail Address (Optional); Mailing Address (Street or P.O. Box); City; State; Zip Code.

Is this change due to a revocation proceeding? Yes No If yes, is there any personal relationship to any of the former related parties? Yes No If yes, explain the relationship.

STATE OF and COUNTY OF; APPLICANT NAME/ AUTHORIZED REPRESENTIVE; APPLICANT SIGNATURE/ AUTHORIZED REPRESENTIVE. Sworn to and Subscribed Before me this Day of, 20, By (print name(s) of person(s) making statement), who is personally known to me OR who produced identification. Commission Expires; Notary Public.

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.

7. Have you been convicted of a felony within the past 15 years? Yes No If yes, provide the information requested and provide a Copy of the Arrest Disposition, as requested in the Application Requirements checklist.

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 and a Copy of the Arrest Disposition. Attach additional sheet if necessary.

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.

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.

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.

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.

SECTION 5 - 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.

When applicable, complete the appropriate section: 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.

OTHER INTERESTS: if you answered yes to any of the OTHER INTERESTS questions, a copy of the agreement must be submitted with this application.

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. Your application will be considered incomplete without this active registration.

Department of Revenue clearance is required on applications for all new, transfer, change of location, and applications which change the licensee's name. Applications must be submitted within 90 days of receiving this approval. The address for the office serving your area of interest can be found at Local ABT Licensing Offices.

Section 4, Sales Tax, is to be completed by the Department of Revenue.

Affidavit of Applicant: read and sign in the presence of a notary.