Mail to: New York State Liquor Authority Brand Label Registration Unit 80 S. Swan Street Suite 900 Albany, NY 12210-8002 (518) 474-6820 Application for: State of New York Executive Department PRIVATE Brand Label Registration (BEER) (ABCL 107-a and 9 NYCRR 84) Division of Alcoholic Beverage Control For STANDARD label brands: use Form 650 Every brand of beer sold in New York State must be registered with the NYS Liquor Authority. This application must be filed IN DUPLICATE by the brand owner. This application must be accompanied by: (A) Copy of the Federal Certification/Exception of Label/Bottle Approval (CoLA) issued by the United States Department of the Treasury, Tax and Trade Bureau. The CoLA must be in complete conformity with the set of labels submitted and the information set forth by the applicant in this application. (B) One complete set of all labels (face, back, neck, etc.) which will appear on containers of the specified brand of beer, securely affixed to the reverse side of one of the application forms. (C) A check in the amount of one hundred fifty dollars ($150) made payable to the NYS Liquor Authority. 1. Name of Retail Licensee Filing this Application 2. Licensee’s Serial Number (7 digit) 3. ( Licensee’s Telephone Number ) 4. Address of Retail Licensee Filing this Application 5. Brand Name of Beer 7. Class: (Beer, Ale, Porter, etc.) 9. Ext. Post Office Address (if different) 6. - Name, Trade Name and Address of Brand Owner 10. Name, Trade Name and Address of NY Wholesale Licensee from whom brand will be purchased 12. Will this brand of beer be sold outside New York State? Country of Origin Name, Trade Name and Address of Brewer 11. 8. (if “Yes”, please briefly explain below) Yes ► No ANY CHANGE IN THE LABELS OR IN ANY OF THE INFORMATION PROVIDED IN THIS APPLICATION MUST BE REPORTED TO THE STATE LIQUOR AUTHORITY WITHIN TEN DAYS AFTER SUCH CHANGE By my signature, I certify that I am the licensee filing this application, or that I have been duly authorized by the licensee to file this application; that I know the contents of this application; and that the statements contained in this application are true to my own knowledge. I certify that I am the exclusive owner of the brand label set forth; and that the brand is sold within the state exclusively by the retail licensee named herein. _________________________ _______________________________________________________ Title Signature _________________________ _______________________________________________________ Date Print (name of person whose signature appears above) ▼ For use by State Liquor Authority ▼ Approved / Disapproved Registration No. Class No. Fee Audited by Form 650.1 (3/07) Private Brand Label - BEER American LegalNet, Inc. www.FormsWorkflow.com