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Name (required)

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Birthday (required)

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Birthday (required)

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Certificate Holder's First Name (required)

Your first name

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Certificate Holder's Middle Name

Your middle name (leave blank if this does not apply)

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Certificate Holder's Last Name (required)

Your last name

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Certificate Holder's Street Address (required)

The current street address you want associated with your TABC certificate.

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Certificate Holder's City and State (required)

The current city and state you want associate with your TABC Certificate.

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Certificate Holder Social Security Number (required)

Your social security number. (TABC requires vaild SSN in order to be assigned a TABC Certificate. )

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Security Question #1 - What was the name of your first pet? (required)

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Security Question #2 - What is your favorite artist? (required)

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Security Question #3 - What is your Grandmothers name? (required)

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Security Question #4 - What is the name of your favorite teacher? (required)

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Security Question #5 - What was the color of your first car? (required)

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Security Question #6 - What is your favorite food? (required)

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Security Question #7 - What is your favorite color? (required)

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Security Question #8 - What city were you born in? (required)

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