Reissue Application {47667}

APPLICATION FOR REISSUE State Form 47667 (R2 / 1-14) Approved by State Board of Accounts, 2014 INDIANA ALCOHOL & TOBACCO COMMISSION 302 West Washington Street, Room E114 Indianapolis, Indiana 46204 Telephone: (317) 232-2430 Web page: www.IN.gov/atc * This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it. The fee for reissue is $10.00. Payment may be made by mail using a money order, business check, or certified check. DO NOT SEND CASH OR PERSONAL CHECKS. FOR OFFICE USE ONLY Cash receipt number Date of reissue (month, day, year) Date of expiration (month, day, year) APPLICANT INFORMATION Name of permittee Social Security Number * Permit number Daytime telephone number ( Address of permittee (number and street, city, state, and ZIP code) ) REISSUE INFORMATION Type of certificate to be reissued (check one) Alcoholic beverage Reason for reissue (check one) Tobacco Business Employee Original document never received (lost in mail) Original document lost Original document stolen Original document destroyed Articles of Amendment (Name change; copy of Articles of amendment must be attached.) Articles of Merger (No change in ownership; copy of Articles of Merger must be attached.) SIGNATURE AND AFFIRMATION I understand that the original certificate is null and void upon reissuance and if I recover the original certificate, I must forward it to the Indiana Alcohol and Tobacco Commission. I affirm under the penalties of perjury that the foregoing representations are true and correct. Signature of applicant Date (month, day, year) Typed or printed name of applicant American LegalNet, Inc. www.FormsWorkFlow.com