Winery Direct Shippers Permit Application {DR 8475}

DR 8475 (07/13/06) COLORADO DEPARTMENT OF REVENUE LIQUOR ENFORCEMENT DIVISION 1375 SHERMAN STREET DENVER CO 80261 (303) 205-2300 FOR OFFICIAL USE ONLY WINERY DIRECT SHIPPER'S PERMIT APPLICATION Phone Number ACCT # ___________________ Note: Only holders of alcoholic beverage licenses that authorize the manufacture of vinous liquor (wineries) are eligible for this permit. 1. Name of Applicant 2. Trade Name of Establishment (DBA) 3. Address of Winery Premises City 4. Mailing Address (Number and Street) County City or Town Yes No AMT PAID $ _________________ State State ZIP Code ZIP Code 5. Is applicant a federally licensed manufacturer of vinous liquor? If so, permit #________________________ (copy of basic permit must be attached) 6. Is applicant licensed by any state as a manufacturer of vinous liquor? Yes No If so, state and license #_______________________ (copy of license must be attached) 7. Does applicant currently have a Colorado wine and spirits importer's license? If so, license # _____________________________________ 8. Do you intend to solicit orders from any Colorado liquor-licensed wholesaler or retailer? (If yes, please explain on a separate sheet) 9. 10. 11. 12. 13. Please name your intended common carrier _______________________________________________________________ Will your shipping container contain language stating that the package may not be delivered to a person Yes No under the age of 21, or to persons who are visibly intoxicated? Do you acknowledge that you are responsible for the payment of all Colorado vinous liquor excise taxes and applicable Yes No surcharges on wines shipped into Colorado? Please attach a check for $50.00 payable to the Colorado Department of Revenue. I have attached copies of Federal Permits/Licenses required in Questions 5 and 6 above. Yes No Yes No Yes No OATH OF APPLICANT I declare under penalty of perjury in the second degree that this application and all attachments are true, correct, and complete to the best of my knowledge. Authorized Signature Title Date DO NOT WRITE BELOW THIS LINE WINERY DIRECT SHIPPER'S PERMIT Name of Licensee License Account Number Period $50.00 December 31, _______ LIABILITY INFORMATION County City Industry Type Liability Date License Issued Through (Expiration Date) 2345-100 (999) TOTAL $ The State may convert your check to a one time electronic banking transaction. Your bank account may be debited as early as the same day received by the State. If converted, your check will not be returned. If your check is rejected due to insufficient or uncollected funds, the Department of Revenue may collect the payment amount directly from your banking account electronically. American LegalNet, Inc. www.FormsWorkflow.com