______________________________________________________________________________
Date ______
I am 21 years of age or over.
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Signature
Description of evidence in support of age and identity:
___Identification No. (if any) ___
___Identification No. (if any) ___
(Fill in information pertaining to any two or more pieces of evidence submitted by the person.)
I hereby certify that I have accurately recorded identification of the evidence submitted to complete this form.
___________________
Signature of permittee or licensee
A person under 21 years of age who knowingly misrepresents the person's true age with the intent of obtaining alcohol in violation of ORS chapter 471 may be subject to criminal penalties under ORS 165.805.
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ORS 471.130