445 Minnesota Street, Suite 222, St. Paul, MN 55101 (651) 201-7500 TDD (651) 282-6555 FAX (651) 297-5259 Minnesota Department of Public Safety ALCOHOL & GAMBLING ENFORCEMENT DIVISION APPLICATION FOR MALT BEVERAGE IMPORTER'S LICENSE License Fee: $1600 TTB Basic Permit or Brewer's Notice Required to Accompany this Application License Expiration Date: Minnesota Tax ID Number: Licensee's Name (as listed on Basic Permit) DBA or Trade Name Main Address of Carrier (as listed on Basic Permit) City Mailing Address (if different from above) State Zip Code License ID Number: Federal Tax ID Number: Date Approved: APPLICANT INFORMATION Business Phone Email Address LIST OTHER STATES WHERE LICENSED DO YOU HAVE AN INTEREST IN ANY RETAIL LICENSE? If yes, please provide name and address We hold a valid and currently effective Federal Basic Qualifying Documents as provided by Alcohol Administration Act of August 29, 1935 (Title 27 U.S. Code, Section 203). We agree to comply with the Minnesota Excise Tax and Alcoholic Beverage Laws and Regulations. Attach Additional Page if Needed Address Address Yes No OFFICER INFORMATION Partner/Officer Name & Title Partner/Officer Name & Title Compliance Officer Name, Title & Company Social Security # Social Security # Address DOB DOB Compliance Officer Name, Title & Company Address Print Full Name of Applicant and Title Signature of Applicant DOB Date All labels must be approved by Alcohol and Gambling Enforcement before an alcoholic beverage may be imported into Minnesota. MAKE CHECK PAYABLE TO: DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT A $30.00 service charge will be added to all dishonored checks. You may also be subjected to a civil penalty of $100 or 100% of the value of the check, whichever is greater, plus interest and attorney fees. Reference Minnesota Statute 340a.302 American LegalNet, Inc. www.FormsWorkFlow.com Updated 4/27/2016 LK Names and Addresses of the Applicant's Minnesota Wholesalers Attach Additional Page if Needed WHOLESALER INFORMATION Address Name Name Address Name Address Name Address Name Address Name Address Name Address Name Address Name Address Name Address American LegalNet, Inc. www.FormsWorkFlow.com