609 Security Statement of Age Verification

609 Security Statement of Age Verification
REPRESENTAION AND STATEMENT OF AGE FOR PURCHASEOF ALCOHOLIC BEVERAGES
Venue
Date

MonthDayYear
Date
Time

:HourMinutesAM/PM Option
Name of Person Presenting ID

First NameLast Name
I understand that misrepresentation of age to induce the sale, service or delivery of alcoholic beverages to me is cause for my arrest, prosecution and punishment which can result in: payment of a fine of not less than $100 – nor more than $1,000; possible imprisonment up to 6 months; mandatory loss or deferment of driver’s license privileges for 6 months; a requirement to participate in an alcohol education or treatment program for a period not to exceed 6 months. Knowing the possible penalties for misstatement, I hereby represent and state for the purpose of inducing this establishment to sell, serve or deliver alcoholic beverages to me, that I was born
Birthdate

MonthDayYear
Date
And I am years of Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature

Clear
Do not write below

To be completed by 609 Security
Identification Presented
Comments:
Reason for Accepting ID
Form Accepted By:

First NameLast Name
Should be Empty:

REPRESENTAION AND STATEMENT OF AGE FOR PURCHASEOF ALCOHOLIC BEVERAGES