HomeMy WebLinkAboutForm - Request to change trade name (dba), address or other contact information (fillable)Rev.
REQUEST TO CHANGE
LICENSEE TRADE NAME (DBA), ADDRESS OR OTHER CONTACT
INFORMATION
Request to Change (check all that apply):
Licensee EXISTING Information
Licensee NEW Information
We request to make the following changes:
For New Trade Name (DBA) attach the following item:
Certificate of Registration of Trade Name from the State of Hawaii DCCA
(Dept. of Commerce & Consumer Affairs).
________________________________________________________________________ _______________________
SIGNATURE Licensee (Owner)/Authorized Agent DATE
__________________________________________________________________________
PRINT Licensee (Owner)/Authorized Agent
Note: If submission by Authorized Agent, please submit a Letter of Authorization signed by the Licensee/Owner.
Licensee Trade Name (DBA) Mailing Address Phone Number(s)Email Address
Other – must specify below
Liquor License No.: Licensee (Owner) Name:
Existing Trade Name (DBA):
Existing Mailing Address:
Existing Phone Number(s): Existing FAX Number:
Existing Email:
New Trade Name (DBA):
New Mailing Address:
New Phone Number(s): New FAX Number:
New Email:
Other change requests described as follows (documentation bay be required):