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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 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 /> <br />Signature <br /> <br />));2-0y- <br /> <br />, ----- <br /> <br />Date <br /> <br />Signature, Notary Public <br /> <br />Date <br /> <br />NOTE: A LIST OF YOUR WHOLESALE SUPPLffiRS MUST ACCOI\1PANY TIllS <br />DRAM SHOP EXEMPTION FORM. <br /> <br />~u <br />fYJc~ <br />~ <br />/j~ <br />jLJ~ <br />/11 M 1flJ- ~ <br /> <br />.~ <br />~ <br />cJ~ <br />GJ~ <br /> <br />/a~ <br />