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2. Business Name*
4. Applicant's Name and Role/Title within the Business*
5. Email Address*
7. Business Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
14. Tax ID#*
16. Alcohol Business License *
    -- Select One --ClubMixed BeverageOff-Premise Consumption On-Premise Consumption Private
18. TABC License *
    -- Select One --FB - Food and Beverage MB - Mixed BeverageBG - Wine and Malt Beverage RetailerBQ - Wine and Malt Beverage Off-PremiseBE - Malt Beverage On-PremiseBF - Malt Beverage Off-PremiseN - Private ClubP - Package Store Q - Wine Only
20. Signature *
22. Submit a copy of TABC license.
Leave This Blank:


24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

* indicates a required field