HomeMy WebLinkAboutForm - Registration Card (fillable)DEPARTMENT OF LIQUOR CONTROL
COUNTY OF HAWAI'I TYPE OR PRINT LEGIBLY IN INK NAME:___________________________________________________________________________________________
(Last) (First) (Middle) (Maiden Name) MAILING ADDRESS:_______________________________________________________________________________
BIRTHDATE:______________________________
(must be at least 21 years of age)
BIRTHPLACE:_____________________________
CITIZENSHIP: U.S. or ALIEN
EMPLOYER: POSITION: D/REGISTERED: EMPLOYER: POSITION: D/REGISTERED:
EMPLOYER: POSITION: D/REGISTERED:
I hereby solemnly swear that the above statements are true.
___________________________________________
(Signature of Applicant)
Hawai'i County Is an Equal Opportunity Provider and Employer