Supplier Application {DLC 1551}

Ohio Department of Commerce Division of Liquor Control, Beer and Wine Section, 6606 Tussing Road, P.O. Box 4005 Reynoldsburg, Ohio 43068-9005 (614) 644-2411 Fax (614) 644-2480 http://www.com.ohio.gov/liqr Division Use Only Reg. Date: S Permit # Check No. Amount $ New Company IMPORTATION OF BEER, WINE, MIXED BEVERAGES, or SPIRITUOUS LIQUOR · Remit application Fee of $100.00 (Non-Refundable) in addition to the Registration Fee (Specified Below) ­ Make check payable to the Division of Liquor Control ­ Allow 30-45 business days for processing (Do not combine this fee with an S or B-2a liquor permit application). Supplier Application · All Supplier Permits expire June 30th of each year with no refund of the fee for any unused portion or proration. · Print or type all information except signature. Failure to respond to all questions will result in the return of this application and delay in applicant's ability to sell products in Ohio. Deliberate falsification of information on this application may result in the Division's refusal to issue the registration for supplier status. · Complete and attach Label Registration Form DLC1511 and fee. · Submit copy of Federal Basic Permit. S-1 Beer, S-3 Spirits, S-4 Mixed Beverages, ........................................................................................................................ $300.00 If you have applied for any classes listed above and you also apply for any of the classes listed below, your fee is $300.00. If you have not applied for any of the classes listed above, your fee is as stated below. S-1 Beer only and has only an S Permit................................................................................................................................................... No Fee S-5 Wine Importer only and produce 250,000 gallons or more................................................................................................................ $300.00 S-5 Wine only and produce less than 250,000 gallons and is entitled to a tax credit under 27 C.F.R. 24.278........................................ $76.00 S-5 Wine only and has an Ohio B-2a permit............................................................................................................................................ $76.00 S-5 Wine only and has only an Ohio S permit.......................................................................................................................................... No Fee PART I Company Name: Company Address: Mailing Address (If different): City: Federal Tax Identification #: State: Zip Code: Telephone #: Name of Contact Person: E-mail Address: Fax #: DBA (doing business as): PART II 1. Does applicant-supplier have any financial interest, direct or indirect, by stock ownership, or interlocking directors in a corporation, or in any other way, in the establishment, maintenance, or promotion of the business of any Ohio wholesale distributor or Ohio retail permit holder? If YES, please attach a written explanation. 2. Do you hold or have you applied for an S permit issued by the State of Ohio (shipment of beer/wine directly to Ohio residents)? If NO, please skip question #3 and go to #4 & Part III. If so, please indicate Permit # 3. If you answered YES to question 2, will you sell your products through an Ohio wholesale distributor? If YES, please submit a Territory Designation Form DLC 1539. 4. Do you agree to comply with all laws of the state of Ohio and rules of the commission concerning alcoholic beverages? YES NO YES YES YES NO NO NO PART III I, NOTE: If the applicant is also the holder of an S permit issued by the state of Ohio and will not sell its products through an Ohio wholesale distributor, it is not necessary to submit a territory designation form. , County of ss. State Of (Please Print Name) and answers made in the foregoing application are true. being first duly sworn, according to law, depose and say that the statements ___________________________________________________________________________ (Signature of Applicant) (To be completed by Notary Public) _____________________ (Title) _______________ (Date) Sworn to before me and subscribed in my presence this ______________day of _____________________________________, 20 _____________. ________________________________________ (Notary Public) DLC 1551 Rev. (10/2013) An Equal Opportunity Employer and Service Provider _______________ (Notary Expiration) TTY Users Dial ORS 1-800-750-0750 American LegalNet, Inc. www.FormsWorkFlow.com