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Industry Circulars 19-2 Attachment A

Sample Request and Certification Under Industry Circular 2019-2

TTB Industry Circular 2019-2
Attachment A

Our Business
123 Main Street
Washington, DC 20005

I am submitting this statement to request participation in the Temporary Voluntary Disclosure Program contained in TTB Industry Circular 2019-2.  I certify that I am authorized to sign for the company listed above and, on behalf of the company, I acknowledge and consent that, if TTB approves the application and issues a new permit, TTB may take action against the new permit for violations that took place prior to the issue date of the new permit.

Chris Smith

Chris Smith,


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Page last reviewed: July 7, 2019
Page last updated: July 7, 2019
Maintained by: Regulations and Rulings Division

Last updated: January 21, 2020