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New Hampshire Affidavit Form

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New Hampshire Affidavit Form
New Hampshire Affidavit Form
State of New Hampshire
Liquor Commission
Division of Enforcement & Licensing
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)
Business Trade Name: Liquor Lic#
(No. – Street)
(City / Town) (State) (Zip)
(No. – Street)
(City / Town) (State) (Zip)
I live at:
(No. – Street)
(City / Town) (State) (Zip)
I was born in on
(POB: i.e. State, or Province if Canada, Country if foreign)
(Date of Birth)
Home phone
Male Female Race Soc. Sec #
I am 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 licensed premise. By signing this a ffidavit I swear this information is true and accurate
and that this document is signed under the penalty if false swearing (RSA 641:2)
Have you ever been arrested for or convicted of a crime that has not been annulled by the court Yes No
If convicted, were you convicted of a felony Yes 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.
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. Date:
Personally appeared before me known to be the person who executed
and made oath that the same is true.
(Affiant Name)
SEAL Justice of Peace / Notary Public
Mail original to: NHLC - Division of Enforcement & Licensing, PO BOX 1795, Concord NH 03302
(Reviewed 8/8/2012, updated 10/1/13, 10/8/13, 04/16/2014)
New Hampshire Affidavit Form