Change In Managing Agents To Sell Beer

Change In Managing Agents To Sell Beer

This form is REQUIRED to be completed when there is a change in managing agents.
For questions regarding this form, contact City Recorder Kimberly Givens at kgivens@cityofdickson.com or 615-441-9508.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Business Information
Name of Business
Address of Business

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Managing Agent Information
Name

First NameLast Name
Address of Managing Agent

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
Driver's License Number
Submit Copy of Driver's License

Cancelof
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I certify I have or have not been convicted of any crime involving liquor laws, abuse of alcoholic beverages, or crimes of moral turpitude.
Type of Conviction
Name of Court
Address of Court

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Conviction

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Managing agent solemnly swears that each statement above is true and that if any statement herein is false, the permit issued pursuant thereto may be revoked by the Beer Board upon notice and hearing, in which the burden shall be on the permittee to prove the correctness of all statements of this affidavit. Managing agent further swears that he or she has been advised that he or she is also subject to all applicable provisions of the Tennessee Code Annotated.
Signature
Should be Empty:

Change In Managing Agents To Sell Beer

Business Information

Managing Agent Information