RISK PERCEPTION

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RISK PERCEPTION

Name of Business *

ARE YOU A NEW APPLICANT?

YES

NO - IF NO, ENTER ABC PERMIT # BELOW

PERMIT NUMBER

What type of Alcohol Outlet is this? *

Convenience Store, Gas Station

Grocery Store

Restaurant

Bar

Chain of Convenience Stores, Gas Stations

Chain of Grocery Stores

Other*

If other please explain

First Name

Last Name

Phone Number

Your Zip Code

Your Email Address

Store: Street Address

Please enter (EXAMPLE) 111 Main Street

Store: Zip Code

Single Store: Telephone Number

Please enter (EXAMPLE) 555-555-5555

AS A STORE OWNER/MANAGER/SUPERVISOR/CONTACT I will help to ensure the following: REQUIRED FOR ALL TYPES OF PERMITS *

ALL ALCOHOL OUTLETS MUST COMPLETE THIS SECTION!

Employees receive Responsible Sales training. (Documentation on file)

ID is checked prior to alcohol sales (Must be 21 years of age or older)

Alcohol is not served or sold if a person is intoxicated

Law enforcement is called or handled as taught during Training in the event of noise/unruly/fighting drugs, etc

Required

NO TOBACCO

Tobacco is NOT sold in this store

NO ELECTRONICS OR VAPE

Product is NOT sold in this store

LOTTERY TICKETS

Lottery tickets are NOT sold in this store

TOBACCO AND/OR LOTTERY TICKETS

ID is checked prior to tobacco sales (must be 18 years of age or older) (see below if you do not sell tobacco)

ID is checked prior to lottery ticket sales (must be18 years of age or older) (see below if you do not sell lottery)

Less than 10% of store windows are covered with signs (It is a Code Violation if more than 10%)

Proper lighting of back and front of store

You may agree to the following: NOT REQUIRED

Willing to send a staff member to the annual APPRECIATION breakfast in April to celebrate your good work!

Willing to place health or substance abuse related prevention infomation at the counter or in the store

Willing to allow access to fresh fruits and vegetables at no expense to you (Non Grocery Stores)

Willing to place a sign "We Card" at a place of your choosing in the store

IS THERE SOMETHING THAT YOU THINK THE PUBLIC WOULD LIKE TO KNOW ABOUT YOU?

IS THERE ANYTHING THAT WE CAN DO TO ASSIST YOU?

Initials *

Your initials serve as your electronic signature

Date

MM/DD/YY

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