Laserfiche WebLink
<br />CITY OF CENTERVILLE <br />INTOXICATION MALT LIQUOR LICENSE <br />APPLICATION <br />DRAM SHOP INSURANCE EXEMPTION <br /> <br />I hereby certify under penalW 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 510,000 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 />fi <br /> <br />Signature <br /> <br /> <br /> <br /> <br />Date <br /> <br />Signature, Notary Public <br /> <br />Date <br /> <br />NOTE: A LIST OF YOUR WHOLESALE SUPPLIERS MUST ACCOMPANY TIllS <br />DRAM SHOP EXEMPTION FORM. <br /> <br />E:u:t- U <br />j1]c~ <br />~ <br />tj~ <br />N~ <br />/11~ 1L/I-~ <br /> <br /> <br />v~ <br />rd~ <br /> <br />~~ <br />