State of California
Department of Alcoholic Beverage Control
DECLARATION RE TEMPORARY PERMIT
Instructions: This form is used when an applicant is not available
to sign Form ABC-280, Temporary Permit.
(Section 24045.5 Business and Professions Code.)
APPLICANT'S NAME (Last, first, middle initial)
PREMISES ADDRESS (Street number and name, city, state, zip code)
CITY, STATE WHERE SIGNED
The above named, being the holder of temporary permit(s) for the
above-designated premises and having made application for transfer of
a license at the above-mentioned premises, declares as follows:
That all current obligations in connection with the purchase of alcoholic
beverages under temporary permit(s) at the above-designated premises
have been discharged, and that all checks issued in payment for
alcoholic beverages purchased while holding the temporary permit(s)
will be honored on presentation.
I declare under penalty of perjury that the foregoing is true and correct.
Distribution: Original to District file.