New Hampshire Affidavit Form

State of New Hampshire
Liquor Commission
Division of Enforcement & Licensing
AFFIDAVIT
This affidavit is filed with the Liquor Commission’s Division of Enforcem ent & Licensin g in supp ort of my ownership,
management control, employment by a business licensed, or applying for a license to sell alcoholic beverages and
tobacco under Chapter 178 of the Revised Statutes Annotated.
I,
being duly sworn do depose and say:
(Print Name)
1.
Business Trade Name:
Address
Mailing
Address
2.
I live at:
3.
I was born in
Liquor Lic#
(No. – Street)
(City / Town)
(State)
(Zip)
(No. – Street)
(City / Town)
(State)
(Zip)
(No. – Street)
(City / Town)
(State)
(Zip)
on
(POB: i.e. State, or Province if Canada, Country if foreign)
Home phone
4.
I am
Male
Female
(Date of Birth)
Race
(Age)
Soc. Sec #
I am not a citizen of the United States
If not a citizen, R.A. Document # or other Identification submitted
5.
I understand RSA 178:4 & RSA 179:23, IV, prohibit c onvicted felons from holding a license to sell alcohol or
assuming control of lic ensed premise. By signing this a ffidavit I swear this informa tion is true and accurate
and that this document is signed under the penalty if false swearing (RSA 641:2)
6.
Have you ever been arrested for or convicted of a crime that has not been annulled by the court? Yes
If convicted, were you convicted of a felony? Yes
7.
No
No
I am filing this document in support of my employment as a
Corporate Officer
POA
Person in Charge
Partner
LLC Member
Proprietor
LLC Manager
Manager
Title/Position
RSA 179:23, IV requires the licensee to designate one or more people to be in charge of the premise in the
licensee’ absence.
8.
I swear before the Justice of Peace or Notary Public that this information is true and accurate, and that this
document is signed under the penalty if false swearing (RSA 641:2)
Signature
Date
County
SS.
Personally appeared before me
and made oath that the same is true.
Date:
known to be the person who executed
(Affiant Name)
SEAL
Justice of Peace / Notary Public
Mail original to: NHLC - Division of Enforcement & Licensing, PO BOX 1795, Concord NH 03302
L-002(Reviewed 8/8/2012, updated 10/1/13, 10/8/13, 04/16/2014)