HomeMy WebLinkAboutForm - Application for Duplicate License (fillable)DEPARTMENT OF LIQUOR CONTROL COUNTY OF HAWAI‘I
Hilo Lagoon Centre, 101 Aupuni St., Unit 230, Hilo, Hawai‘i 96720 * Phone: (808)961-8218 * Fax: (808)961-8684
E-Mail: cohdlc@co.hawaii.hi.us
APPLICATION FOR DUPLICATE LIQUOR LICENSE
TO THE LIQUOR COMMISSION OF THE COUNTY OF HAWAI‘I:
The undersigned hereby applies for a duplicate liquor license to replace the following:
License No. Effective Date
(Give the number and effective date of the license which has been lost)
Class Kind
(Dispenser, Retail, etc.) (General, Beer and Wine, Beer)
Issued to (Name of Licensee)
Doing business as
For the premises located at (Street address or location of business)
The licensee for which this duplicate is asked was lost or destroyed in the matter
indicated below and is no longer in the possession of the licensee. (State as accurately as
possible the manner in which the license was lost or destroyed and date of occurrence.)
The undersigned certifies that this application for a duplicate of the above described
license is made in good faith and that every statement contained herein is true, unless stated on
information and belief, and in such case the statements are believed to be true. Further, the undersigned agrees to return to the commission, if found, the original license which was believed to have been lost or destroyed.
Licensee:
By (Signature)
Name:
Title:
Date:
Phone No.:
E-Mail:
Hawai‘i County is an Equal Opportunity Provider and Employer
DEPARTMENT OF LIQUOR CONTROL COUNTY OF HAWAI‘I
Hilo Lagoon Centre, 101 Aupuni St., Unit 230, Hilo, Hawai‘i 96720 * Phone: (808)961-8218 * Fax: (808)961-8684
E-Mail: cohdlc@co.hawaii.hi.us
STATE OF HAWAI‘I
COUNTY OF HAWAI‘I
)
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SS.
On ___________________, before me personally appeared __________________ to me
known to be the person described in and who executed the foregoing instrument, and acknowledged that the person executed the same as the person’s free act and deed.
Notary Public, State of Hawai‘i Printed Name: ________________
My commission expires: _________
NOTARY CERTIFICATION STATEMENT Document Identification or Description: .
Doc. Date: ________________or Undated at time of notarization. No. of Pages: ______________ Jurisdiction: Third Circuit
_______________________________________________________ Signature of Notary Date of Notarization and Certification Statement
______________________ Printed Name of Notary
Hawai‘i County is an Equal Opportunity Provider and Employer