REPRESENTATION AND STATEMENT
OF AGE
FOR PURCHASE OF ALCOHOLIC
BEVERAGES
I understand that misrepresentation of age to induce the sale, service, or delivery of alcoholic beverages to me is cause for my arrest and prosecution, which can result in punishment as follows:
Knowing the possible penalties for misstatement, I hereby represent and state, for the purpose of inducing _________________
(Name of licensee)
to sell, serve, or deliver alcoholic beverages to me, that I was born:
________, _______, ______ and am ____ years of age.
(Month) (Day) (Year)
Date __________ | Signed _______________________ |
Address ______________________ | |
____________________________ | |
Other Identification | Signature of person who witnessed completion of this statement by patron: |
Presented: | |
Nonphoto driver's | |
license: (number & state) | |
________________________ | ____________________________ |
Social Security Number | |
____________________________ | |
Other _______________________ | |
____________________________ | |
____________________________ |
IC 7.1-5-7-5.1