Consent To Transfer Stock

CONSENT TO TRANSFER STOCK State Form 18663 (R / 9-10) Approved by State Board of Accounts, 2011 INDIANA ALCOHOL AND TOBACCO COMMISSION IGCS Room E114 302 West Washington St Indianapolis, IN 46204 Telephone number: 317 / 232-2430 Fax number: 317 / 233-6114 www.IN.gov/atc Permit Number: ____________________________________ I, _________________________________________________, having on the _____ day of __________________________________, 20____, held ___________ shares of Common Stock in ___________________________________________ located at ___________________________________________________________________, _____________________________________ County, formally notify the Alcohol and Tobacco Commission that I consent to the transfer of _____________ shares of stock. SUBJECT TO APPROVAL OF TRANSFER BY THE ALCOHOL AND TOBACCO COMMISSION I certify that all information provided herein and on any attachments are true and correct. I understand that it is a felony to misrepresent or falsify any portion of this document or attached documents. _____________________________________________________________________ Signature _____________________________________________________________________ Date (month, day, year) American LegalNet, Inc. www.FormsWorkFlow.com