Declaration Of Age - Pennsylvania

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 CRIMINAL PENALTIES INCLUDING FINES, IMPRISONMENT AND/OR LOSS OF DRIVING PRIVILEGES FOR ANY MISREPRESENTATION HEREIN. (Person Requesting Service)

The PLCB reserves the right to furnish the Declaration of Age card to any appropriate law enforcement agency.

Identification Shown ________________________________ Signature Compared - Yes _______No Race ___________ Sex _____ Complexion __________ Hair Color _________ Weight ______ Height Code Requested ____________Time_________ Reason Refused

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