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<br />CITY OF CENTERVILLE <br />INTOXICATION MALT LIQUOR LICENSE <br />APPLICATION <br />DRAM SHOP INSURANCE EXEMPTION <br /> <br />I hereby cenify under penalty of petjury that I have applied for an intoxicating liquor/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 />r!!J} <br /> <br />Signature, Notary Public <br /> <br />ignature@). <br />m <br />J~ <br /> <br />Dme' ~ '. <br /> <br /> <br />(!JI~ <br /> <br />Date <br /> <br />NOTE: A LIST OF YOUR WHOLESALE SUPPLIERS MUST ACCOMPANY TIllS <br />DRAM SHOP EXEMPTION FORM. <br /> <br /> <br />,. <br /> <br />)D07 <br />0fJf <br /> <br />3Z <br />