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<br />CITY OF CENTERVILLE <br />INTOXICATION MALT LIQUOR LICENSE <br />APPLICATION <br />DRAM SHOP INSURANCE EXEMPTION <br /> <br />I hereby certify under penalty of perjury that I have applied for an intoxicating Iiquor/on- <br />sale wine license and that the sales of such beverages are less than $10,000 per year. In <br />addition. I certifY that the attached list of my wholesale suppliers is true and correct. If <br />necessary, these suppliers may be contacted in order to confirm this declaration. <br /> <br /> <br />Date <br /> <br />/0 ,S~ ()b <br />, <br /> <br />Signature, Notary Public <br /> <br />Date <br /> <br />NOTE: A LIST OF YOUR WHOLESALE SUPPLIERS MUST ACCOMPANY THIS <br />DRAM SHOP EXEMPTION FORM. <br />NE6DHAfYJ OJS). - o/J1-dSJS <br />J10~f.1J5-(lIrV - ~51- }J5 ' Vi7g <br />~'J/1A11/0f( OiJ I. - 6,5/- Yf;J -J /33 <br />(lL OiJ;JALD ~/.5i, -bIJ' 339-5YoJ <br />j11f.iR J(}?II - bS I - b Vb - bD63 <br />'JOH,JJu;J DRIlS I - 6~q - SgotJ <br />q.- <br />P~tLtJIPS - 637 - 3300 <br /> <br />15 <br />