Acknowledgement Of Receipt Of A Wine Delivery {DSA-AR}

FORMAT for an ACKNOWLEDGEMENT OF RECEIPT OF A WINE DELIVERY to be used by a Common Carrier when delivering Wine Sold and Shipped Directly to a New York Residential Customer for such Customer's Personal Use and Not for Resale from a New York State Licensed Wine Manufacturer or from the holder of an Out-of-State Direct Shipper's License issued by New York State [As required by Alcoholic Beverage Control Law §§ 79-c.(3)(e)(ii), 79-d.(1)(e)(ii)] ACKNOWLEDGEMENT OF RECEIPT OF A WINE DELIVERY CARRIER CONFIRMATION OF IDENTIFICATION PRESENTED BY THE WINE RECIPIENT CARRIER'S NAME CARRIER'S ADDRESS CARRIER ACCOUNT NUMBER ASSIGNED TO THIS WINERY-SHIPPER CARRIER DELIVERY NUMBER ASSIGNED TO THIS DELIVERY CARRIER'S NEW YORK STATE LICENSE NO. WINERY-SHIPPER'S NAME WINERY-SHIPPER'S ADDRESS WINERY-SHIPPER'S FEDERAL BASIC PERMIT NO. WINERY-SHIPPER'S HOME STATE WINERY LICENSE NO. WINERY-SHIPPER'S NEW YORK STATE OUT-OF-STATE DIRECT SHIPPER'S LICENSE NO. NAME OF PERSON RECEIVING ITEM ADDRESS OF PERSON RECEIVING ITEM INSTRUCTIONS FOR COMPLETING THE ACKNOWLEDGEMENT OF RECEIPT OF A WINE DELIVERY CARRIER CONFIRMATION OF IDENTIFICATION PRESENTED BY THE WINE RECIPIENT THE CARRIER MUST MAINTAIN AN ELECTRONIC OR PAPER RECORD DOCUMENTING THAT THE RECIPIENT OF THE WINE PRESENTED PROPER AND VALID IDENTIFICATION. ACCEPTABLE FORMS OF IDENTIFICATION TYPE OF IDENTIFICATION PRESENTED BY THE WINE RECIPIENT CHECK ONE BOX IN EACH OF THE TWO COLUMNS BELOW, AND SPECIFY ADDITIONAL FACTS AS REQUIRED IDENTIFICATION WAS ISSUED BY (SPECIFY ADDITIONAL FACTS WHERE REQUIRED) New York State Other State ______________________________ (Specify) Federal Government United States Territory, Commonwealth, or Possession (Specify)______________________ District of Columbia Provincial Government of the Dominion of Canada The United States Government Valid Passport The Country of ___________________________ (Specify) (1) EXAMINE THE IDENTIFICATION PRESENTED BY THE PROPOSED RECIPIENT. DO NOT ACCEPT A FORM OF IDENTIFICATION UNLESS YOU ARE FULLY FAMILIAR WITH ITS CONTENTS AND HAVE CAREFULLY COMPARED THE PHOTOGRAPH ON THE IDENTIFICATION WITH THE PERSON PRESENTING IT Valid Driver's License Valid Non-Driver Identification Card (2) MAKE A RECORD OF THE TYPE OF IDENTIFICATION YOU EXAMINED. FOR EXAMPLE, IF A NEW YORK DRIVER'S LICENSE IS PRESENTED, CHECK THE FIRST BOX IN THE LEFT HAND COLUMN, AND THE FIRST BOX IN THE RIGHT HAND COLUMN. (3) SPECIFY ANY ADDITIONAL FACTS REQUIRED, SUCH AS THE NAME OF ANOTHER STATE, TERRITORY, COUNTRY, OR BRANCH OF ARMED FORCES. (4) RECORD THE DATE THE IDENTIFICATION PRESENTED WILL EXPIRE. Valid Identification Card issued by the Armed Forces of the United States EXPIRATION DATE OF IDENTIFICATION PRESENTED Identify Branch of the Armed Forces _____________________ (Specify) SIGNATURE OF PERSON RECEIVING THE WINE DELIVERY (5) GET THE SIGNATURE OF THE PERSON RECEIVING THE WINE DELIVERY. (6) RECORD THE NAME OF THE EMPLOYEE MAKING THE DELIVERY. / Month Day / Year TIME OF DELIVERY DATE OF DELIVERY (7) RECORD THE TIME AND DATE OF DELIVERY. NAME OF THE EMPLOYEE MAKING THE WINE DELIVERY AM PM Hour Minute Month / Day / Year (Revised 09-30-05) American LegalNet, Inc. www.FormsWorkflow.com