Grain Alcohol Permit Application

VIRGINIA DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL APPLICATION FOR GRAIN ALCOHOL PERMIT INSTRUCTIONS There is no charge for this permit. Complete and return application to: LICENSE RECORDS MANAGEMENT VIRGINIA DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL 2901 HERMITAGE ROAD P O BOX 27491 RICHMOND VA 23261-7491 BUSINESS Company name Steet address City County PURPOSE Intended use: Virginia ZIP+4 PURCHASING Purchase to be made from ABC store number: Store address City County Estimate the amount of 190 proof grain alcohol required: BOTTLE SIZE G 375 ML G 1.75 L APPLICANT Applicant name Title Signature Daytime phone number Virginia PER MONTH ZIP OR PER YEAR 805-75 American LegalNet, Inc. www.FormsWorkflow.com FOR OFFICE USE ONLY SPECIAL AGENT G Culinary G Commercial G Industrial G Medical Purpose: Comments: Recommendation: Signature G Approval G Denial Date Territory number SPECIAL AGENT IN CHARGE Permit number Special Agent assigned City/County G Culinary G Commercial G Industrial Effective date Date District G Medical Purpose: Recommendation: G Approved G Denied Date Signature American LegalNet, Inc. www.FormsWorkflow.com