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it/011 <br />u ty <br />DBPR ABT-6014 — Division of Alcoholic Beverages and Tobacco Change of Location/Change g r <br />in Series or Type Application 4 <br />STATE OF FLORIDA DBPR Form <br />DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ABT -6014 <br />Revised 07/30/2012 <br />A6/4.157 <br />NOTE — This form must be submitted as part of an application packet <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 Informa;*imay-an be <br />found on AB&T's page of the DBPR web site at the link provided below. ,-;:i'FIGATION ON LAST PAGE <br />JRIG,\ '\L -` C <br />http.//www.myflorida.com/dbpr/abt/district offices/licensing.htmf 'j• r\IIIT•H CLERK <br />SECTION 1 - CHECK TRANSACTION REQUESTED <br />Transaction Type: <br />■ Change of Location <br />❑ Increase in Series <br />❑ Change in Series <br />❑ Decrease in Series <br />Also include <br />❑ Change of Business Name <br />❑ Change of Officer/Stockholder/Amended <br />Corporate Name <br />❑ Retail Tobacco Products (must check one or more) <br />❑ Pipes ❑ Over the Counter ❑ Vending Machine <br />Do you wish to purchase a Temporary License? ❑ Yes ❑ No <br />Series Requested <br />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) <br />BOARD OF COUNTY COMM OF INDIAN RIVER COUNTY <br />Department of State Document # <br />BEV4100436 <br />FEIN Number* <br />59-6000674 <br />Business Telephone Number <br />772-226-1410 ext <br />Current Business Name (D/B/A) <br />BOCC OF IRC / SANDRIDGE GOLF CLUB <br />Current License # <br />BEV4100436 <br />Series <br />4COP <br />Type/Class <br />SCC <br />New Business Name (D/B/A), if applicable <br />Location Address (Street and Number) <br />5300 73RD STREET <br />City <br />VERO BEACH <br />County <br />INDIAN RIVER <br />State <br />FL <br />Zip Code <br />32960 <br />Check either <br />❑ Location is within the city limits or ■ Location is in the unincorporated county <br />Contact Person (Optional) <br />MICHAEL C ZITO, ASSISTANT CTY ADMINISTRATOR <br />Telephone Number <br />772-226-1410 ext <br />E -Mail Address (Optional) <br />MZITO@IRCGOV COM <br />Mailing Address (Street or P 0 Box) <br />1801 27TH STREET <br />City <br />VERO BEACH <br />State <br />FL <br />Zip Code <br />32960 <br />ABT District Office Received / Date Stamp <br />Auth. 61A-3.020 & 61A-5.0017, FAC 1 <br />Eff. 7/30/12 <br />