Application For A Wholesalers Manufacturers Intoxicating Liquor License

Minnesota Department of Public Safety ALCOHOL AND GAMBLING ENFORCEMENT DIVISION 444 Cedar Street, Suite 222, St. Paul, MN 55101 (651) 201-7500 TDD (651) 282-6555 FAX (651) 297-5259 APPLICATION FOR A WHOLESALER'S/MANUFACTURER'S INTOXICATING LIQUOR LICENSE License Expiration Date: Workers Comp. Ins, Co. Minnesota Tax ID Number Licensee's Name (business, partnership, LLC, corporation) Business address City Warehouse Date of Incorporation City State Certificate Number State DOB License Number: Date Approved: Policy Number Federal Tax ID Number Social Security Number DBA or Trade Name Fax Number License Period From Phone Number Zip Code To State Is the corporation authorized to do business in Minnesota? Yes No Bond - $10,000 Bond - $1,000 Bond - $5,000 Bond - $1,000 Bond - $5,000 Bond - $1,000 Bond - None Bond - $5,000 Only necessary for new licensees after Jan 1, 2010 Indicate type: Submit a certified check and a surety bond in the amount specified. Wholesaler of Intoxicated Liquor Fee $15,000 Brewer (brews over 3500 barrels annually) Brewer (brews between 2000 - 3500 barrels annually) Wholesaler of Wine Wholesaler of Malt Beverages Wine Manufacturer Micro Brewer (brews under 2000 barrels annually) Brew Pub Farm Winery Manufacturer Fee - $30,000 Fee - $4,000 Fee - $500 Fee - $3,750 Fee - $1,000 Fee - $500 Fee - $150 Fee - $500 Fee - $50 Give full name, address, DOB, Social Security number and title of the applicant and for all partner or officers and principal stockholders for corporations, State below the partnership interest of each partner and for a corporation the percentage of stock held by each officer. DOB Social Security Number Title Percent of partner interest Name Address Name Address Name Address DOB DOB City Social Security Number City Social Security Number City Title State Title State State Zip Code Percent of partner interest Zip Code Percent of partner interest Zip Code MAKE CHECK PAYABLE TO: DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT AMOUNT RECEIVED American LegalNet, Inc. www.FormsWorkFlow.com Describe the storage and warehousing facilities and/or the bottling and production capacity and the number of floors used. List basic federal permit and other permit numbers with their effective dates. Permit Type Permit Type Permit Number Permit Number Effective Date Effective Date Give the address of all branch establishments owned by the applicants in Minnesota. Street address, city Street address, city State whether applicant or any person named herein own any stock or have financial interest in any brewery, manufacturer, wholesaler or retail alcoholic beverage establishment in this State or any other State. State whether applicant, partners, or officers were ever indicted or convicted for any violation of the Minnesota Liquor Control Act or a felony in this State or any other State or under federal laws. Manufacturers and Brewers: Names of Minnesota Wine and Beer Wholesalers. (Attach additional sheet if needed) Wholesalers of malt beverages: State the name and address of the producers of the beverages to be distributed. All statements and documents submitted with this application shall become a permanent part of the record. The Alcohol and Gambling Enforcement Director has the right to reject or revoke any license or license application containing a false statement. I CERTIFY THAT THE INFORMATION SUBMITTED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. Print Full Name of Applicant and Title Signature of Applicant Date NOTE If this application is for a new partnership, submit a certified copy of the partnership agreement. For a new corporation, include a certified copy of the articles and by-laws. If this application is for a license renewal, submit a copy of any amendment made to the partnership agreement or the articles of incorporation and by-laws since the last license was issued. Identification cards must be obtained for each salesperson employed. Fee is $35 per card and will expire at the same time as this license. American LegalNet, Inc. www.FormsWorkFlow.com