Section 1 of 1 in this document
Alcohol Licensee Delinquent Notices From Wholesalers
Notice of
Delinquent Retailer
Paid Delinquency
Name of Licensee
*
Business Name
*
License Number(s)
*
Full Address
Street Address
*
City
*
State
*
Zip
*
Phone Number
Email
*
Date of Invoice
*
Amount of Invoice OR Returned Check
Date of Delinquency
Date Paid
Amount Paid
Wholesaler
*
Wholesaler's Address
Street Address
City
State
Zip
Acknowledgement Required
I certify that the written notice of delinquency required under ARSD 64:75:04:04 has been provided to the delinquent retailer and a copy of the notice of delinquency is attached.
Please Upload the Written Notice of Delinquency
Click Here to Upload
Sign Here
Sign Here
First Name
Last Name
Email
Choose how to sign
Draw
Type
By electronically signing this document, I certify that I am authorized to sign and that the above information is true and correct.
Additional Email
Additional Email 2
Additional Email 3
Additional Email 4
disregard this