Colorado Wine Packaging Permit {DR 8008}

DR 8008 (05/09/14) COLORADO DEPARTMENT OF REVENUE Liquor Enforcement Division PO Box 173350 Denver, CO 80217-3350 303-205-2300 Colorado Wine Packaging Permit Name of Applicant exactly as it appears on your current Colorado Liquor License Trade Name of Applicant Business Address of Applicant Mailing Address (Number and Street) Email Address City City or Town State Sales Tax No. Applicant License No. Business Telephone County ( ) State State Zip Code Zip Code This application for a wine packaging permit may be granted to the above named applicant with an acknowledgment of the following: I affirm that the above entity is a licensed winery, limited winery or wholesaler; I understand that I must only accept product for packaging from another winery or manufacturer and that the federal excise tax on the product I am packaging has already been paid; I understand that, if the above entity is a winery or limited winery, that it cannot sell or distribute the packaged wine to a licensed retailer or directly to consumers. Oath Of Applicant I declare under penalty of perjury in the second degree that this application and all attachments are true, correct, and complete to the best of my knowledge. I also acknowledge that it is my responsibility and the responsibility of my agents and employees to comply with the provisions of the Colorado Liquor or Beer Code which affect my license or permit. Authorized Signature Print Name Title Date (MM/DD/YY) Do Not Write In This Space - For Department Of Revenue Use Only Date License Issued (MM/DD/YY) License Account Number Period (MM/YY - MM/YY) From: To: Total Fees: Please visit www.colorado.gov/revenue/liquor for more information. Wine Packaging Permit: $200.00 American LegalNet, Inc. www.FormsWorkFlow.com