2. Assumption Parish Police Jury Application for Occupational License
4. ***Licenses become due and payable January 1st, and become delinquent April 15th
6. Date*
   Date
   Enter the date
7. Phone Number*
   Enter your phone number
9. Trade Name:*
   Enter your trade name
10. Owner Name:*
    Enter the Business owner's name
12. Business/Contact Email Address:*
    Enter the business/contact email address
14. Physical Location of Business:*
    Enter the physical address of the business
16. Mailing Address
    Enter your address if it is different from the physical address
18. Applicant Data:
20. Is the applicant of good character and reputation and over eighteen (18) years of age?*

    1. Yes
    2. No
22. Is the applicant a citizen of the United States? (Citizenship and Residency requirements of Louisiana must exceed a continuous period of 2 years from the date of the filing of the application.)*

    1. Yes
    2. No
24. Is the applicant the owner of the premises or has a bona fide written lease?*

    1. Yes
    2. No
26. Has the applicant ever been convicted of a felony in the US or Louisiana?*

    1. Yes
    2. No
28. Has the applicant ever been convicted of soliciting for prostitution, pandering, letting premises for prostitution, contributing to the delinquency of juveniles, keeping a disorderly place, or illegally dealing in narcotics?*

    1. Yes
    2. No
30. Has the applicant ever had a license or permit to sell or deal in alcoholic beverages issued by the US, any state, or any political subdivision of a state, revoked within one (1) year prior to this application?*

    1. Yes
    2. No
32. Has the applicant been convicted or had a judgement of court rendered against him involving alcoholic beverages by this or any other state or by the US for one (1) year prior to this application?*

    1. Yes
    2. No
34. Has the applicant been adjudged or convicted of violating any provision of this part or any municipal/parish ordinances?*

    1. Yes
    2. No
36. Is the applicant the spouse of a person whose application has been denied or whose permit has been revoked, unless judicially separated or divorced?*

    1. Yes
    2. No
38. Is the applicant a partnership or in partnership with or financed by another? If yes, the application shall state the full names of all partners and persons financially interested and furnish their proper addresses and each shall furnish his affidavit showing his qualifications, as required of an applicant.*

    1. Yes
    2. No
40. If above answer is yes, enter names and addresses of all partners and/or persons financially interested.
42. BUSINESS DATA:
44. Type of business, profession, vocation, etc.:*
    Enter the type of business, profession, vocation, etc.
46. Does your business dispense food and/or beverages?*

    1. Yes
    2. No
48. Does your business dispense alcoholic beverage?*

    1. Yes
    2. No
50. Does your business have a video poker machine?*

    1. Yes
    2. No
52. Does your business have amusement devices?*

    A list of machines and locations must accompany this application.

    1. Yes
    2. No
54. If applicable, upload a list of machines and locations:
56. Exceptions to occupational license: Peddlers, Fireworks, and Fairs
58. ***If any of the above qualifications are not possessed by the applicant, the permit may be denied at the discretion of the police jury.
60. THE ISSUANCE OF THIS LICENSE DOES NOT EXEMPT THE TAXPAYER FROM OBTAINING ANY NECESSARY STATE OR PARISH PERMITS/LICENSES.
62. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, 3) you may still be required to provide a traditional signature at a later date, and 4) you grant permission and give authority to the Assumption Parish Police Jury to run a background check on your name. The information obtained is to be used to determine if you are suitable to be granted a liquor license permit. The signing electronically of this form, is to be considered as notification that a background check will be run and that a liquor license application will not be considered for approval until the background check is complete and clear.

    1. I agree.
64. Electronic Signature*
66. ***AFTER APPROVAL FROM THE POLICE JURY, APPROVED APPLICATION EMAIL SHOULD BE TAKEN TO THE ASSUMPTION PARISH SHERIFF'S OFFICE FOR ISSUANCE OF ACTUAL OCCUPATIONAL LICENSE WITHIN 10 DAYS.
68. Secretary-Treasurer Approval

    By checking the "I approve" box below, you agree and acknowledge that 1) your approval will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, 3) you may still be required to provide a traditional signature at a later date, and 4) you are approving this occupational license.

    1. I approve.
70. Electronic Signature
71. Date of Approval
    Date of Approval
Leave This Blank:


73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit

* indicates a required field