.......... 19
I,.......... hereby represent to .........., a State Store or licensee of the board, that I am of full age and discretion and over the age of 21 years, having been born on .......... 19... at ..........
This statement is made to induce said store or licensee above named to sell or otherwise furnish alcoholic beverages to the undersigned.
Serial Number of Identification Card:
I understand that I am subject to a fine of $300.00 and sixty days imprisonment for any misrepresentation herein.
....................................................... | |
(Name) | |
....................................................... | |
(Address) |
Witness:
Name..........
Address..........
The forms shall be printed in a manner approved by the board and shall be filed alphabetically by the State Liquor Store or licensee in a file box containing a suitable alphabetical index at or before the close of business on the day that the form is executed, and any such form shall be subject to examination by any officer, agent or employe of the enforcement bureau at any and all times.
47 P.S. § 4-495