Connoisseurs License Application Return to: Montana Department of Revenue Liquor Licensing PO Box 1712 Helena, MT 59624-1712 MONTANA Conapp Rev 02 11 NOTICE: All importers, wineries and breweries must be registered or licensed with the Department of Revenue prior to shipping into Montana. For necessary forms, please call us toll free at (866) 859-2254 (in Helena, 444-6900). Section 1 – Required Fees and License Information This license must be renewed on an annual basis by June 30.       Beer ...................................$50 Wine ...................................$50 Beer/Wine Combo ............$100 Please provide proof of age  Copy of birth certificate   Driver’s license Other state-issued ID Section 2 – General Information Applicant Name ____________________________________________________________________________________ Mailing Address ____________________________________________________________________________________ Number and Street City State Zip Shipping Address___________________________________________________________________________________ Number and Street City State Zip Social Security Number - - Telephone Number _________________________________ Section 3 – Questions Do you agree to furnish semi-annual (June 30 and December 31) reports to the Department of Revenue showing the quantity of product and pay applicable taxes due?  Yes  No Do you agree to faithfully comply with all State of Montana laws and all Department of Revenue rules and regulations pertaining to the shipping of products? (Refer to 16-4-901; 16-4-902; 16-4-903; 16-4-910; 16-6-301, MCA.)  Yes  No Section 4 – Declaration and Affidavit This application is made for the purpose of licensing the above-mentioned connoisseur. Montana law states “upon proof that any applicant made false statements in any part of the application, the application for license may be denied, and if issued the license may be revoked” (16-4-402, MCA). I/We declare under penalty of false swearing that the information provided on this application and its attachments is true, correct and complete. Applicant Signature _____________________________________________________Date ________________________ Print Name____________________________________________________________ *11MM0101* *11MM0101* American LegalNet, Inc. www.FormsWorkFlow.com