Affidavit of Surrender - DenverAffidavit of Surrender City and County of Denver Department of Excise...
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Affidavit of Surrender City and County of Denver Department of Excise and Licenses 201 W. Colfax Avenue, Dept. 206 Denver, Colorado 80202 720-865-2740 Please email this completed form to [email protected]. Respondent represents that this surrender of the Respondent's license, __________-BFN-_____________, is made voluntarily by the Respondent, and that Respondent is not surrendering the aforesaid license as a result of any threat, promise, or coercion by the Department of Excise and Licenses (the "Department") or any of its agents or employees. Any promise or representation made by any agent or employee of the Department not contained herein shall be null, void, and unenforceable. Respondent acknowledges that immediately upon the acceptance of this surrender by the Director, Respondent's license and all related licensed privileges, will be canceled, terminated, and voided for the remainder of the unexpired term of the license without exception. If the Respondent later wishes to again hold a valid license and licensed privileges, it will be necessary for the Respondent to make a new application with the Department for a license. Respondent understands that the Director will recognize faxed signatures or signatures sent by .pdf and that such executed copy of this request is authorized to create an effective original hereof and shall have the full force and effect of an original executed instrument. License Address Printed Name Date __________________________________________ __________________________________________ __________________________________________ __________________________________________ Signature
Transcript of Affidavit of Surrender - DenverAffidavit of Surrender City and County of Denver Department of Excise...
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Affidavit of SurrenderCity and County of Denver
Department of Excise and Licenses201 W. Colfax Avenue, Dept. 206
Denver, Colorado 80202720-865-2740
Please email this completed form to [email protected].
Respondent represents that this surrender of the Respondent's license, __________-BFN-_____________, is made voluntarily by the Respondent, and that Respondent is not surrendering the aforesaid license as a result of any threat, promise, or coercion by the Department of Excise and Licenses (the "Department") or any of its agents or employees.
Any promise or representation made by any agent or employee of the Department not contained herein shall be null, void, and unenforceable. Respondent acknowledges that immediately upon the acceptance of this surrender by the Director, Respondent's license and all related licensed privileges, will be canceled, terminated, and voided for the remainder of the unexpired term of the license without exception. If the Respondent later wishes to again hold a valid license and licensed privileges, it will be necessary for the Respondent to make a new application with the Department for a license.
Respondent understands that the Director will recognize faxed signatures or signatures sent by .pdf and that such executed copy of this request is authorized to create an effective original hereof and shall have the full force and effect of an original executed instrument.
License Address Printed Name
Date
__________________________________________ __________________________________________
____________________________________________________________________________________Signature
YEAR: NUMBER: License Address: Printed Name: Date: Signature:
