Designation Of Authorized Distribution Form

ATTACHMENT B DESIGNATION OF AUTHORIZED DISTRIBUTOR FORM The undersigned, which is applying for issuance or renewal of an importer' license to sell and deliver or ship the brands of beer s and/or wine listed in Paragraph 2 of the attached Importer Designation and Authorization Form Attachment A, hereby files with the Virginia Alcoholic Beverage Control Board this list of wholesaler licensees which are authorized by the undersigned, as the authorized representative of _________________________________ (Name of Brand Owner), to distribute such brands within the Commonwealth of Virginia. Date: _______________________________ ____________________________________________________________ Name of Applicant for Importer's Licensee/or Importer Licensee ____________________________________________________________ Signature of Person Executing Form and Title of Position Name of Designated Distributor And Distributor License # License Number Address of Designated Distributor Designated Territory or Primary Area of Responsibility 1)_____________________________________ _________________________________ ________________________________________________ 2)_____________________________________ _________________________________ ________________________________________________ 3)_____________________________________ _________________________________ ________________________________________________ 4)_____________________________________ _________________________________ ________________________________________________ 5)_____________________________________ _________________________________ ________________________________________________ 6)_____________________________________ _________________________________ ________________________________________________ 7)_____________________________________ _________________________________ (Use Supplemental Sheet If Necessary) ________________________________________________ Rev. 3/01 American LegalNet, Inc. www.FormsWorkflow.com