Petition for Hearing
To: West Virginia Alcohol Beverage Control Administration Commissioner
900 Pennsylvania Avenue, 4th Floor
Charleston, WV 25302
(For Commission Use Only)
Docket No. _______
Date of Order of Suspension or Revocation or Denial of Application for License:
Whether Suspension or Revocation or Denial of Application for License
In the Matter of: Petitioner's Business Name
Petitioner's ABCA License No.
Address
The above named against whom you have issued an order of (Revocation or Suspension or Denial of Application for License), and in support of such petition avers as follows:
First: Your petitioner admits as true and correct all of the determinations made by the Commissioner and set forth in the above order and basis thereof, except the following: (Specify here each error which the petitioner alleges to have been made by the Commissioner.)
Second: (Set forth clear and concise statements of fact upon which the petitioner relies as sustaining the assignment of error.)
Wherefore, your petitioner prays (insert relief sought, i.e., this order be set aside).
State of ___________________)
Business Name ________________________________)
SS Signature of Affiant__________________________)
County Of ____________________________________)
Title ____________, being duly sworn according to law, deposes and says that the facts alleged in this petition, including any sheets attached hereto, are true and affiant is the petitioner or is duly authorized to represent the petitioner.
By: _________________
Sworn to and subscribed before me this __________ day of ________, 20 ___ at ___________.
______________________________
Notary Public
My commission expires ___________
Notary Public
W. Va. Code R. § 175-2-6