INSTRUCTIONS FOR PROPER FILING OF YOUR APPLICATION PLEASE READ PRIOR TO COMPLETING THIS FORM 1. An application fee of $25.00, payable to the Alcoholic Beverage Control must be returned with this completed application. 2. The applicant’s signature must be notarized by a licensed Notary Public. 3. Submit either an original application for a sales tax number (green form), a copy of the sales tax application, or if already granted a sales tax number, list the number in Item II of the application form. 4. Locate on this application form the ownership classification of the applicant, whether a sole owner, partnership, corporation, trust or other. Note the instructions on who must file qualifying documents (PERSONAL RECORD, form 1001). Be sure to complete the PERMITTEE CERTIFICATION AND OATH ending this portion of the application. 5. Complete the WAIVER AND AUTHORIZATION TO RELEASE INFORMATION. This release will assist us in verifying the information on your application. 6. You are required to publish notice of your application in two (2) consecutive issues of a newspaper published in the town in which the business will be located. If no local newspaper exists, the notice may be published in the newspaper produced in the town located nearest your business and within the same county. The notice must be published in its entirety in TEN POINT BOLD FACE TYPE. An acceptable legal notice format is included in this packet. Submit with this application a PUBLISHER’S AFFIDAVIT (obtained from the newspaper) as proof of publication. NOTICE: ALL NEW PERMITTEES DURING THEIR FIRST 90 DAYS ARE ON "CERTIFIED FUNDS" STATUS. ORDERS FOR ALCOHOLIC BEVERAGES MUST BE PAID WITH A MONEY ORDER OR CERTIFIED CHECK FOR THE AMOUNT OF PURCHASE AND ANY FEES DUE. NEITHER PERSONAL CHECKS NOR COMPANY CHECKS ARE ACCEPTABLE. CASH IS ACCEPTED ONLY IF DELIVERED IN PERSON. BRING EXACT AMOUNT DUE, CHANGE IS NOT AVAILABLE. American LegalNet, Inc. www.FormsWorkflow.com LEGAL NOTICE FORMAT FOR PUBLICATION OF ORIGINAL PERMIT APPLICATION CHECK APPLICABLE PHRASES ( ) I,_________________________________________________________________ (sole owner’s name) ( ) We, the partners of__________________________________________________ (partnership name) ( ) We, the officers of__________________________________________________ (corporation name) intend to make application for an Alcohol Processing permit as provided for by the Local Option Alcoholic Beverage Control Laws, Section 67-1-1, et seq., of the Mississippi Code of 1972, Annotated. If granted such permit, ( ) I ( ) We propose to operate as a ( ) sole owner ( ) partnership ( ) corporation under the tradename of ___________________________________________ located at ______________________________________________________ (street) (city) of _________________________. (county) The name(s), title(s) and address(es) of the owner(s)/partner(s)/corporate officer(s) and/or majority stockholder(s) of the above named business are _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ This the______day of _______________,19____ American LegalNet, Inc. www.FormsWorkflow.com PERMIT DEPT. USE ONLY AMT. OF CHECK__________ CHECK NUMBER_________ PERMIT NUMBER_________ ALCOHOL PROCESSING PERMIT APPLICATION I. APPLICANT: _______________________________________________ ( name of sole owner, partnership, or corporation) MAILING ADDRESS: _________________________________________ (street/post office box) II. (city) (state) (zip) BUSINESS: ________________________________________________ (trade name) ADDRESS: _________________________________________________ (street) (city) (zip) COUNTY: ________________ Sales Tax Number __________________ III. TYPE OF APPLICANT ENTITY: ( ) Sole Owner ( ) Partnership ( ) Trust ( ) Corporation ( ) Other ________________________ IV. Have you or any member of your partnership or association, or any officer, director, or majority stockholder of your corporation, ever been convicted of any of the following: a felony regardless of its nature in any state or federal court, a violation of the Local Option Alcoholic Beverage Control Laws, a violation of any other law relating to alcoholic beverages, beer or light wine, or a violation of any drug related law? _____________ If "yes", explain fully: _________________________________________ __________________________________________________________ __________________________________________________________ V. How are alcoholic beverages used, or planned to be used, as an integral ingredient in your manufacturing process?_________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ VI. Anticipated total amount, in gallons, of alcoholic beverages used in your manufacturing process annually:_________________________________ American LegalNet, Inc. www.FormsWorkflow.com VII. Will this business be operated as a sole ownership by the person applying for this permit?_______If "yes"", submit a PERSONAL RECORD (Form 1001), with this application. VIII. Will this business be operated as a partnership? _____ If "yes", list each partner’s name and extent of his interest in the partnership. NAME HOME ADDRESS AMT. OF INTEREST OWNED ___________________________ ___________________________ ____________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ ________________________ ________________________ ________________________ _______________________________ NOTE: Each partner must submit a PERSONAL RECORD (Form 1011) with this application. IX. Will this business be operated as a corporation?________If "yes" list the total amount of stock,___________ common and____________preferred, and each officer, director, and majority stockholder below. Include a copy of the corporate charter and attach a list of all stockholders, amount of stock owned, and their addresses to this application. NAME CORP. TITLE _______________________ ___________ ADDRESS ______________________ SHARES OWNED ________________________ _______________________ ___________ ______________________ ______________________ ______________________ ________________________ _______________________ ___________ ______________________ ________________________ ______________________ NOTE: Each officer, director, and majority stockholder must submit a PERSONAL RECORD (Form 1011). X. Will this business be operated as a trust? ______If "yes", list the trustee and each beneficiary below. NAME ____________________________ TYPE ________________________ STATE OF RESIDENCY ________________________ ____________________________ ________________________ ________________________ ____________________________ ________________________ ________________________ NOTE: Each trustee must submit a PERSONAL RECORD (Form 1011) with this application. American LegalNet, Inc. www.FormsWorkflow.com CERTIFICATION AND OATH I,__________________________________, certify under penalty of perjury that the organization applying for this Alcohol Processing Permit does meet the qualifications for Sections 67-1-37, 67-1-51 (i), 67-1-55, 67-1-57 and 67-1-59. I affirm that this organization, in the exercise of this permit, will comply with the Local Option Alcoholic Beverage Control Laws, Rules and Regulations, relative to the purchase, sale, and handling of alcoholic beverages and will keep all records and make all reports and remittances as required thereby. I certify that the information presented on the application to be true and correct, to the best of my knowledge and belief. ____________________________ Date___________________________________ SIGNATURE _____________________________________ TITLE SWORN TO AND SUBSCRIBED before me, this the_________day of________________________,_____. My commission expires: ____________________ ______________________________________________ NOTARY PUBLIC _______________________________________________________ _______________________________________________________ WAIVER AND AUTHORIZATION TO RELEASE INFORMATION TO WHOM IT MAY CONCERN: I authorize you to furnish the Alcoholic Beverage Control Division, State Tax Commission, with any and all information that you may have concerning me, my work record, my reputation, and my military service records. You may allow inspection of records by, and copies of these records may be provided to, an authorized representative of the Alcoholic Beverage Control Division. Information of a confidential or privileged nature may be included. Your reply will be used by the Commission in determining my fitness and eligibility to be granted an Alcoholic Beverage Control Permit. A reproduction of this request by Xerox or similar process shall be for all intents and purposes as valid as the original. I hereby release you, your organization and others from liability or damage which may result from furnishing the information requested. ____________________________ _____________________ APPLICANT’S SIGNATURE DATE WITNESSES’ SIGNATURES ________________________________ _______________________________ American LegalNet, Inc. www.FormsWorkflow.com APPLICATION ALCOHOL PROCESSING PERMIT 402 RETURN TO ALCOHOLIC BEVERAGE CONTROL DIVISION PERMIT DEPARTMENT P.O. BOX 540 MADISON, MS. 39130-0540 American LegalNet, Inc. www.FormsWorkflow.com