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III'D if <br /> DBPR ABT-6014—Division of Alcoholic Beverages and Tobacco Change of Location/Change g <br /> in Series or Type Application <br /> STATE OF FLORIDA DBPR Form <br /> DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ABT-6014 <br /> NOTE—This form must be submitted as part of an application packet Revised 07/30/2012 <br /> If you have any questions or need assistance in completing this application, please contact the <br /> Department of Business and Professional Regulation or your local district office. Please submit your <br /> completed application to your local district office. This application may be submitted by mail, through <br /> appointment, or it can be dropped off. A District Office Address and Contact/nformgiTq,," fan be <br /> found on AB&T's page of the DBPR web site at the link provided below. "FIC AT�9e b LASTPitGE <br /> http://www.myflorida.com/dbpr/abt/district offices/licensing.htm SMITH, CLERK <br /> SECTION 'I -CHECK TRANSACTION REQUESTED <br /> Transaction Type: <br /> 0 Change of Location ❑ Increase in Series <br /> ❑ Change in Series ❑ Decrease in Series <br /> Also include: <br /> ❑ Change of Business Name ❑ Retail Tobacco Products (must check one or more) <br /> ❑ Change of Officer/Stockholder/Amended <br /> Corporate Name ❑ Pipes ❑ Over the Counter ❑ Vending Machine <br /> Do you wish to purchase a Temporary License? ❑ Yes ❑ No <br /> Series Requested Type/Class Requested <br /> SECTION 2;-LICENSE INFORMATION <br /> If the applicant is a corporation or other legal entity, enter the name and the document number as registered with <br /> the Florida Department of State Division of Corporations on the line below. <br /> Full Name of Licensee: (This is the name the license is issued in) Department of State Document # <br /> BOARD OF COUNTY COMM OF INDIAN RIVER COUNTY BEV4100436 <br /> FEIN Number* Business Telephone Number <br /> 59-6000674 772-226-1410 ext <br /> Current Business Name (D/B/A)BOCC OF IRC/SANDRIDGE GOLF CLUB Current License# Series Type/Class <br /> BEV4100436 4COP SGC <br /> New Business Name (D/B/A), if applicable <br /> Location Address (Street and Number) <br /> 5300 73RD STREET <br /> CCounty State <br /> Zip Code <br /> VERO BEACH INDIAN RIVER FL 32960 <br /> Check either: <br /> ❑ Location is within the city limits or W Location is in the unincor orated count <br /> Contact Person (Optional) Telephone Number <br /> MICHAEL C.ZITO,ASSISTANT CTY ADMINISTRATOR 1772-226-1410 ext <br /> E-Mail Address (Optional) <br /> MZITO@IRCGOV.COM <br /> Mailing Address (Street or P.O. Box) <br /> 1801 27TH STREET <br /> City State Zip Code <br /> VERO BEACH FL 32960 <br /> ABT District Office Received /Date Stamp <br /> Auth.61A-3.020&61A-5.0017,FAC 1 Eff. 7/30/12 <br />