Document Form

Full Name

Address

DOB

SSN

Sex

Race

Drivers License #

State

Phone Number

Employer

Permit Number

Name

I hearby swear and affirm (please check one)

I am a United States Citizen I am a Legal Permanent Resident I am a qualified alien or non-immigrant

Alien/USCIS Number for non-citizens

The undersigned applicant also hereby verifies that he or she is 18 years of age or older and provided at least one secure and verifiable document as required by O.C.G.A 50-26-1 (e)(i), with this affidavit. The secure documents can best be classified as:

Document Verification

Printed Name

If Legal Permanent Resident applies I-551 card #

Type of permit

Code:

Alcoholic Beverarge Sell or Dispense Application

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