Industry Representative License Application {WLD-5}

WLD-5 (4/18) LICENSE TYPE CLASS A REPRESENTATIVE- FEE $100.00 CLASS B REPRESENTATIVE- FEE $50.00 CLASS C REPRESENTATIVE- FEE $10.00 1. Are you 18 years of age or older? W.S 12-4-103 (a)(vii) YES NO 2. Are you domiciled (currently living) in Wyoming? W.S. 12-2-203 (b) YES NO 3. Do you presently hold any interest (directly or indirectly) in any type of retail liquor license or retail malt beverage permit within the State of Wyoming? Chapter 20, Section 5 (a) YES If "Yes," please attach a full explanation. NO 4. Have you been convicted of a felony or a violation of federal or state statutes relating to sale or manufacture of alcoholic beverages in the ten (10) years preceding this application? W.S. 12-4-102 (a)(iii)/ Chapter 20, Section 5 (a) YES NO 5. Have you ever had a liquor or industry representative license denied, canceled, suspended or revoked? YES If "Yes," please attach a full explanation. NO CLASS A APPLICANTS 6. Are you currently employed by a licensee as defined in W.S.12-1-101(a)(viii)? YES NO 7. Have you attached a written statement from each vendor whose products you propose to represent? W.S. 12-2-203 (b) YES NO (a) The verification shall verify the employment or contractual agreement and contain a request for you to be licensed to represent it's particular brand or brands in Wyoming. Rules, Section 8, (d) Please Complete the Back Page 6601 Campstool Road Cheyenne, Wyoming 82002 - 0110 INDUSTRY REPRESENTATIVE LICENSE APPLICATION / / $ Cash Recpt #: Check Ck #: Processed by: Payment Processed: / / Control Number: LICENSE TERM: // through JUNE 30, 20 Rep #: Applicant: Business Name (DBA) : Residence Address : Street City State Zip Mailing Address: Street /PO Box City State Zip Home Phone: ( ) - Business Phone: ( ) - Email Address: Fax Number: ( ) - American LegalNet, Inc. www.FormsWorkFlow.com WLD-5 (4/18) 8. List below all liquor, wine, or malt beverage manufacturers, wholesalers, rectifiers, importers, etc., which you will represent within the State of Wyoming. Describe your employment/contractual arrangements with each company, i.e., salaried, commission, etc. Attach complete list of companies if you represent more than one. COMPANY REPRESENTED EMPLOYMENT/CONTRACTUAL ARRANGEMENT Salaried E mployee Contract E mployee Salaried E mployee Contract E mployee Salaried E mployee Contract E mployee Salaried E mployee Contract E mployee CLASS B APPLICANTS The above applicant is a: salaried employee contract employee As the class A representative, I request the above applicant be licensed to represent products represented under my class A representative license. W.S. 12-2-203 (c) /Rules, Chapter 20, Section 8 (d) 100 // A Representative Signature Date CLASS C APPLICANTS 9. Are you 21 years of age or older? W.S 12-2-203 (d) YES NO As the class A representative, I request the above applicant be licensed for the following event. Chapter 20, Section 8 (d) Event Date(s) Event Name: 100 // A Representative Signature Date I have read and understand the laws and rules of the State of Wyoming regarding the advertisement and promotion of alcoholic beverages and will abide by these laws and rules. I understand that violation of these laws and rules may constitute cause for denial, suspension or revocation of my license. / / Signature of Applicant Date American LegalNet, Inc. www.FormsWorkFlow.com