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Get OR Service Permit Application 2012

I also been issued a permit OAR 845-009-0015. OLCC will not notify licensees of application denials. Applicant Signature I understand that my application may be refused or my service permit revoked if my answers on this application are not true and complete ORS 471. 380 ORS 471. 385. Providing a false statement to the OLCC is a misdemeanor crime subject to penalties imposed by the court. Service Permit Application OLCC Permits PO Box 22297 Milwaukie OR 97269-2297 Please read the instruction page before filling out this form. You and an authorized person i.e. owner of a licensed premises authorized temporary employment agency ASE instructor must sign this application. The authorized person must make sure the form with the correct non-refundable fee is mailed to the OLCC before you sell or serve alcohol. The Commission will return your application if it is incomplete. 380 ORS 471. 385. Providing a false statement to the OLCC is a misdemeanor crime subject to penalties imposed by the court. I also understand that I must pass an ASE course within 45 days or this application will be denied ORS 471. 375 to sign below. I understand that I must immediately transmit this application with the correct fee to the OLCC. I also understand that I must pass an ASE course within 45 days or this application will be denied ORS 471. 542. Date Authorized Signature I have verified the age and identity of this applicant and am authorized as a check one Licensee/Manager Authorized Temporary Agency Provider/Instructor OLCC Employee under ORS 471. Attach a separate sheet of paper if needed. Have you been convicted of or had a diversion for DUII Driving Under the Influence of Intoxicants within the past 10 years List conviction s date s city state county. Applicant Signature I understand that my application may be refused or my service permit revoked if my answers on this application are not true and complete ORS 471. Send check or money order only NO CASH Replacement Card Your permit was lost or stolen or your name has changed* You do not need an authorized signature for this request. New Permit 23 Includes Your permit expired or will expire within 6 months. You must have an authorized signature for this request. Name First Middle Social Security Last Date of Birth - Month Day Year Mailing Address Phone City State Zip Identification State of issue Driver license DMV ID card passport Male Female Height lbs Yes No Have you ever been convicted of a felony List conviction s date s city state county. Attach a separate sheet of paper if needed* Have you been convicted of or had a diversion for DUII Driving Under the Influence of Intoxicants within the past 10 years List conviction s date s city state county. 380 ORS 471. 385. Providing a false statement to the OLCC is a misdemeanor crime subject to penalties imposed by the court. I also understand that I must pass an ASE course within 45 days or this application will be denied ORS 471. 542. Date Authorized Signature I have verified the age and identity of this applicant and am authorized as a check one Licensee/Manager Authorized Temporary Agency Provider/Instructor OLCC Employee under ORS 471. .

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