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New Hampshire Business Entity Affidavit Form

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New Hampshire Business Entity Affidavit Form
New Hampshire Business Entity Affidavit Form
Liquor Commission
Division of Enforcement & Licensing
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Business Entity Affidavit
This affidavit is filed with the Liquor Commission’s Bureau of Enforcement and Licensing in support my ownership of,
management control of, or employment by a business licensed or applying for a license to sell alcoholic beverages under
Chapter 178 of the Revised Statutes Annotated. The Entity Affidavit is filed by a licensee/applicant’s manager or officer
attesting to the statement that the entity has not been convicted of a felony.
1. I, being duly sworn do depose and say:
(Print Name of Officer of LLC Manager filing the Affidavit)
2. I live at
(# - Street) (City/Town) (State) (Zip)
3. I was born in /
(Place of Birth – Town/City State Country)
(Date of Birth)
(Age)
4. I am a (member/officer/manager) of a (Limited Liability Company/Limited Liability Partnership/Corporation) applying
for a license to sell alcoholic beverages in New Hampshire. The identity of the applicant is:
Applicant’s Name:
Business Trade Name:
Pending License Number:
1a. ADDRESS:
(# - Street) (City/Town) (State) (Zip)
1b. MAILING ADDRESS:
5. Identify any State in which the applicant holds a license to sell alcohol
6. As an agent of the applicant, I swear the entity, which is a member or officer or manager of the applicant has never
been convinced of a felony, or any offense that would be classified as a felony had it been committed with the State
of New Hampshire, by any state in the United States, the United States government, or any other jurisdiction. I
understand RSA 178:4 and RSA 179:23, IV, prohibit convicted felons from holding a license to sell alcohol
or assuming control of licensed premise. By signing this affidavit I hereby authorize and give consent to
the Bureau of Enforcement & Licensing to inquire and examine all records of my conviction(s), if any, using
all investigative methods available to them. This authorization is given to support or to contradict my
declaration that I have not been convicted of a felony crime. (AFFIANT INITIAL HERE)
7. 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 of false swearing, (RSA 641:2)
(Signature)
(Date)
ss.
(County)
(Date)
Personally appeared before me
(Affiant name)
known to be the person
who executed the above affidavit and made oath that the same is true.
Justice of Peace/Notary Public
SEAL
L-035
(Reviewed 8/31/10)
Phone: (603) 271-3521
New Hampshire Business Entity Affidavit Form