Application for a New York State New York State Division of Alcoholic Beverage Control State Liquor Authority Out-of-State Direct Shipper’s License Alcoholic Beverage Control Law § 79-c – (Calendar Year) (Page 1 of 7) [OSDSL 02 (8-24-05)] This is an application to be used by a person * (1) who holds a Basic Permit to manufacture wine issued by the Alcohol and Tobacco Tax and Trade Bureau (TTB) of the United States Department of the Treasury, AND AND (2) who holds a wine manufacturer’s license issued by a State other than New York State, (3) who – by virtue of such out-of-state wine manufacturer’s license – is authorized to sell wine produced by the manufacturer at retail, packaged in sealed containers for consumption off the winery premises, to customers for personal use and not for resale. New York State Liquor Authority approval of this application will authorize the Out-of-State Wine Manufacturer to directly sell and ship to a New York State resident customer, for personal use and not for resale, limited quantities of wine produced by the Out-of-State Wine Manufacturer. In providing the requested information, please type or print legibly using black ink. All questions must be answered. If a question does not apply to the Applicant, please indicate this by writing “Not Applicable”. If more space is needed to fully answer a question, please attach additional sheets as needed and make reference to the appropriate sheet(s) by writing in the answer box “See Attached Sheet(s) No. ___ .” A LICENSE FEE OF $125.00, MADE PAYABLE TO THE NEW YORK STATE LIQUOR AUTHORITY, MUST BE SUBMITTED WITH THIS APPLICATION, ALONG WITH ALL OF THE ITEMS LISTED ON PAGE 4. * “Person” – as defined at ABCL § 3(22) – includes a legal entity such as a partnership or corporation, as well as an individual who is a sole proprietor. APPLICANT 1. Name of Applicant: 2. Street Address of Applicant: 3. City, Town, or Village: 4. State and 9-Digit ZIP Code: 5. Telephone Number: 6. E-Mail Address: 7. FAX Number: 8. Web Site Address: - - - - CONTACT PERSON 9. Name of Contact Person: 10. Status of Contact Person – for example, sole proprietor, managing partner, corporation president, attorney 11. Contact’s Street Address: 12. City, Town, or Village: 13. State and 9-Digit ZIP Code: 14. Contact’s Telephone Number: 15. Contact’s E-Mail Address: 16. Contact’s FAX Number: 17. - - - - Contact’s Web Site Address: American LegalNet, Inc. www.FormsWorkflow.com Application for a New York State New York State Division of Alcoholic Beverage Control State Liquor Authority Out-of-State Direct Shipper’s License Alcoholic Beverage Control Law § 79-c – (Calendar Year) (Page 2 of 7) [OSDSL 02 (8-24-05)] FEDERAL AND STATE LICENSURE 18. Does the Applicant hold a Basic Permit issued by the TTB in accordance with the Federal Alcohol Administration Act? 19. Does the Applicant hold a State License to manufacture wine? 22. 24. Yes Ō No Ō Yes Ō No Ō Yes Ō No Ō If the answer to Item No. 21 is “YES”, please provide the State Wine Manufacturer License identification number: Is the applicant – by virtue of the State Wine Manufacturer License – authorized to sell wine produced by the manufacturer at retail, packaged in sealed containers for consumption off the winery premises, to customers for personal use and not for resale? Ō If the answer to Item No. 21 is “YES”, please identify the State that issued the State Wine Manufacturer License: 23. No If the answer to Item No. 18 is “YES”, please provide the Plant Registry/Basic Permit/Brewer No.: 21. Ō If the answer to Item No. 18 is “YES”, please provide the TTB Vendor Code (if any): 20. Yes NEW YORK STATE STATUTORY REQUIREMENTS 25. Has the applicant or (if a partnership) any of the partners or (if a corporation) any of the officers, directors or stockholders any interest, directly or indirectly, in any New York premises or in any New York business where any alcoholic beverages are sold at retail, whether by stock ownership, interlocking directors, mortgage or lien on, or ownership of any real or personal property, or by any other means, including loans? Nature of Interest in New York Retail Premises or New York Retail Business Not Applicable If the answer to question No. 25 is “NO”, please check “Not Applicable”. 26. 27. If the answer to Item No. 25 is “YES”, please identify on an attached sheet each New York retail premises and each New York retail business; the New York alcoholic beverage license number associated with each New York premises or New York business; the date each interest was acquired; and the exact nature of each interest. Has the applicant or (if a partnership) have any of the partners or (if a corporation) have any of the officers, directors or stockholders ever been CONVICTED (including pleas of guilty or suspended sentences) of any FELONY or of any other CRIME or OFFENSE of any kind except traffic infractions? Information regarding Convictions Applicant’s New York Retail Interests are disclosed in attached Sheet(s) No. ______ Yes Ō No Not Applicable If the answer to question No. 27 is “NO”, please check “Not Applicable”. 28. If the answer to Item No. 27 is “YES”, please state the date of each conviction, specify each crime or offense, and the name of the person convicted. In each case, a Certificate of Disposition or a Certificate of Conviction certified by the Court Clerk must be attached. Applicant’s Convictions are disclosed in attached Sheet(s) No. ______ Ō Ō Ō Ō Ō American LegalNet, Inc. www.FormsWorkflow.com Application for a New York State New York State Division of Alcoholic Beverage Control State Liquor Authority Out-of-State Direct Shipper’s License Alcoholic Beverage Control Law § 79-c – (Calendar Year) (Page 3 of 7) [OSDSL 02 (8-24-05)] NEW YORK STATE STATUTORY REQUIREMENTS - CONTINUED 29. Are there any ARRESTS, INDICTMENTS, SUMMONSES or other ACCUSATORY INSTRUMENTS (except for traffic infractions) pending against the applicant or (if a partnership) any of the partners or (if a corporation) any of the officers, directors or stockholders? Information regarding Pending Charges Yes Ō No Not Applicable If the answer to question No. 29 is “NO”, please check “Not Applicable”. 30. If the answer to Item No. 29 is “YES”, please state the date of each arrest, indictment, summons or other accusatory instrument, specify each crime or offense alleged, and the name of the person accused. In each case, a copy of the instrument alleging the pending offense must be attached. Applicant’s Pending Charges are disclosed in attached Sheet(s) No. ______ Ō Ō Ō FEDERAL AND STATE TAX REQUIREMENTS 31. Please state your Federal Employer Identification Number: 32. Please state your New York Certificate of Authority Identification Number: 33. Have you filed an application with the New York State Department of Taxation and Finance for a License to conduct business as a New York State Liquor Distributor? 34. If the answer to Item No. 33 is “YES”, please indicate the date on which the application was transmitted, and specify the office with which the application was filed. Yes Ō No Ō Yes Ō No Ō RECIPROCITY 35. Does your State permit a New York State wine manufacturer to engage in the direct retail sale and shipment of wine produced by such New York wine manufacturer, packaged in sealed containers for consumption off the winery premises, to resident customers of your State for personal use and not for resale? 36. If the answer to Item No. 35 is “YES”, please attach the ruling of your State’s alcoholic beverage control commission with respect to the issue of direct retail wine sale and shipment reciprocity with New York State. 37. What is the maximum number of cases of wine (no more than 9 liters per case) that a New York State winery may sell and ship directly to a resident of your State per MONTH? 38. What is the maximum number of cases of wine (no more than 9 liters per case) that a New York State winery may sell and ship directly to a resident of your State per YEAR? 39. Do you agree – as a formal condition of receiving a New York State Out-of-State Direct Shipper’s License – that you will limit your direct sale and shipment of wine to a New York State resident customer to the lesser of the following quantities: [a] no more than 36 cases per year or [b] no more than the maximum number of cases per month and per year that your State allows New York wine manufacturers to directly sell and ship to a resident customer of your State? Ruling regarding Reciprocity is attached as Sheet(s) No. ______ Yes Ō No Ō American LegalNet, Inc. www.FormsWorkflow.com Application for a New York State New York State Division of Alcoholic Beverage Control State Liquor Authority Out-of-State Direct Shipper’s License Alcoholic Beverage Control Law § 79-c – (Calendar Year) (Page 4 of 7) [OSDSL 02 (8-24-05)] CURRENT DISTRIBUTION OF APPLICANT’S WINES WITHIN NEW YORK STATE 40. Within the past twelve months, have any of the Applicant’s wines been imported into New York State by a New York State licensed wholesaler for wholesale and retail sale? Yes Ō No Ō Not Applicable Information regarding Importation of Applicant’s Wines into New York State Ō If the answer to question No. 40 is “NO”, please check “Not Applicable”. 41. If the answer to Item No. 40 is “YES”, please list the Wines that were (or are being) imported into New York State, their TTB ID Numbers, and provide the name and address of the wholesaler importing each such wine. Applicant’s Wines that are being imported into NYS, and the names of the importing NYS Wholesalers are disclosed in attached Sheet(s) No. ______ Ō ITEMS THAT MUST BE ENCLOSED WITH THIS APPLICATION IN ADDITION TO SUCH OTHER AND ADDITIONAL ITEMS WHOSE SUBMISSION MAY BE DIRECTED BY AN EMPLOYEE OF THE AUTHORITY, THE FOLLOWING ITEMS MUST BE ENCLOSED WITH THIS APPLICATION: A. B. C. D. E. F. G. H. I. A money order, check, or bank draft in the amount of one hundred twenty-five dollars ($125.00), made payable to the NEW YORK STATE LIQUOR AUTHORITY. A true and complete copy of the Applicant’s Federal Basic Permit. (x-ref Question No. 18) A true and complete copy of the Applicant’s State Wine Manufacturer’s License together with a true copy of such additional State license(s) or permit(s) (if any) authorizing the Applicant wine manufacturer to sell wine produced by the wine manufacturer at retail, packaged in sealed containers for consumption off the winery premises, to customers for personal use and not for resale. (x-ref to Question No. 21) Item Enclosed? Yes Ō No Ō Item Enclosed? Yes Ō No Ō Item(s) Enclosed? Yes Ō No Additional Sheet(s) reporting the Applicant’s interest in any New York premises or in any New York business where alcoholic beverages are sold at retail. (x-ref to Questions No. 25-26) Item(s) Enclosed? Additional Sheet(s) reporting the Applicant’s convictions, together with a certified copy of a Certificate of Disposition or Certificate of Conviction, with respect to each conviction, from the appropriate Court, Department of Corrections, Parole Board, or Probation Department. (x-ref to Questions No. 27-28) Item(s) Enclosed? Additional Sheet(s) reporting the Applicant’s pending charges, together with a true copy of any indictment, summons, or other accusatory instrument with respect to each charge. (x-ref to Questions No. 29-30) Item(s) Enclosed? A true copy of the Applicant’s New York State Certificate of Authority issued pursuant to New York State Tax Law § 1134. (x-ref to Question No. 32) Ō Item(s) Enclosed? A ruling from the Applicant wine manufacturer’s State that – following amendment of the New York State Alcoholic Beverage Control Law to authorize the issuance of Out-of-State Direct Shipper’s Licenses – a New York State wine manufacturer may directly sell and ship (or may apply for a license to directly sell and ship) wine produced by such New York State wine manufacturer to a resident customer of the Applicant’s State for personal use and not for resale. (x-ref to Questions No. 35-36) List of brands of wine produced by the Applicant that are being imported into NYS for wholesale and retail sale, their TTB ID Numbers, and the name and address of the NYS licensed wholesaler importing each such wine. (x-ref to Questions No. 40-41) Yes Yes Yes Yes Ō Ō Ō Ō No No No No Ō Ō Ō Ō Item Enclosed? Yes Ō No Ō Item Enclosed? Yes Ō No Ō American LegalNet, Inc. www.FormsWorkflow.com Application for a New York State New York State Division of Alcoholic Beverage Control State Liquor Authority Out-of-State Direct Shipper’s License Alcoholic Beverage Control Law § 79-c – (Calendar Year) (Page 5 of 7) [OSDSL 02 (8-24-05)] CONDITIONS OF LICENSURE THE APPLICANT VOLUNTARILY ACCEPTS THE FOLLOWING CONDITIONS IN CONNECTION WITH THE ISSUANCE OF AN OUT-OF-STATE DIRECT SHIPPER’S LICENSE, AND AS AN APPLICANT AND LICENSEE WILL ABIDE BY THE FOLLOWING CONDITIONS: 1. Prior to obtaining an out-of-state direct shipper's license, the Applicant will obtain from the New York State Department of Taxation and Finance a Certificate of Authority pursuant to section eleven hundred thirty-four of the New York State Tax Law. 2. Prior to obtaining an out-of-state direct shipper's license, the Applicant will file an application with the New York State Department of Taxation and Finance for registration as a distributor of alcoholic beverages pursuant to sections four hundred twenty one and four hundred twenty-two of the New York State Tax Law. 3. The Licensee will ensure that the outside of each shipping container used to ship wine to a New York State resident is conspicuously labeled with the words: CONTAINS WINE FOR PERSONAL USE AND NOT FOR RESALE SIGNATURE OF PERSON AGE 21 OR OLDER REQUIRED FOR DELIVERY DELIVERY TO AN INTOXICATED PERSON IS FORBIDDEN BY LAW 4. Twice per year, the Licensee will submit to the New York State Liquor Authority, in a manner and in a form directed by the State Liquor Authority, a WINE MANUFACTURER’S REPORT OF ALL WINE PRODUCED BY THE MANUFACTURER THAT WAS DIRECTLY SOLD AND SHIPPED TO NEW YORK STATE RESIDENT CUSTOMERS FOR PERSONAL USE AND NOT FOR RESALE 5. In connection with the acceptance of an order for a delivery of wine to a New York resident, the Licensee will require the prospective customer to represent x x 6. that he or she has attained the age of twenty-one years or more, and that the wine being purchased will not be resold or introduced into commerce. In connection with the delivery of wine produced by the Licensee and directly sold and shipped to a New York State resident customer for personal use and not for resale, the Licensee will require the common carrier delivering the wine to (i) (ii) require a recipient to sign an electronic or paper form or other acknowledgement of receipt as approved by the State Liquor Authority; and (iii) 7. require the recipient, at the delivery address, upon delivery, to demonstrate that the recipient is at least twenty-one years of age by providing a valid form of photographic identification authorized by Alcoholic Beverage Control Law § 65-b; refuse delivery when the proposed recipient appears to be under twenty-one years of age and refuses to present a valid form of photographic identification authorized by Alcoholic Beverage Control Law § 65-b. The Licensee will file returns with and pay to the New York State Department of Taxation and Finance all State and local sales taxes and excise taxes due on sales into New York State in accordance with the applicable provisions of the New York State Tax Law relating to such taxes, the amount of such taxes to be determined on the basis that each sale in this State was at the location where delivery is made. American LegalNet, Inc. www.FormsWorkflow.com Application for a New York State New York State Division of Alcoholic Beverage Control State Liquor Authority Out-of-State Direct Shipper’s License Alcoholic Beverage Control Law § 79-c – (Calendar Year) (Page 6 of 7) [OSDSL 02 (8-24-05)] CONDITIONS OF LICENSURE – CONTINUED 8. The Licensee will keep records for three years and permit the New York State Liquor Authority or the New York State Department of Taxation and Finance to perform an audit upon request. 9. The Licensee, by the submission of this application for an Out-of-State Direct Shipper’s License, hereby consents to the jurisdiction of New York State, its agencies and instrumentalities, and the Courts of New York State concerning enforcement of section 79-c of the New York State Alcoholic Beverage Control Law and any related laws, rules, or regulations, including tax laws, rules or regulations. 10. The Licensee, in connection with the exercise of the license privilege conferred by the Out-of-State Direct Shipper’s License, will sell only wines that it manufactures. 11. The Licensee, in connection with the exercise of the license privilege conferred by the Out-of-State Direct Shipper’s License, will sell wine only to New York State resident customers for personal use and not for resale. 12. The Licensee, in connection with the exercise of the license privilege conferred by the Out-of-State Direct Shipper’s License, will not directly or indirectly sell wine to New York State licensed retailers. 13. The Licensee agrees – as a formal condition of receiving a New York State Out-of-State Direct Shipper’s License – that the Licensee will fully comply with all applicable requirements of the New York State Alcoholic Beverage Control Law and the Rules of the New York State Liquor Authority. 14. The Licensee agrees – as a formal condition of receiving a New York State Out-of-State Direct Shipper’s License – that the Licensee will limit the direct sale and shipment of wine to a New York State resident customer to the maximum number of cases per month and per year that the Licensee’s State allows New York wine manufacturers to directly sell and ship to a resident customer of the Licensee’s State. 15. The Applicant agrees that, prior to issuance of the applied-for license, the Applicant will notify the Authority, within 48 hours, by certified mail, return receipt requested, of a change in any fact that was reported or required to be reported in connection with this application. Such written notice shall be sent to the following address: New York State Liquor Authority, Director of Licensing, 84 Holland Avenue, Albany, NY 12208 / Attention: Out-of-State Direct Shipper’s License Unit 16. The Licensee agrees that, after issuance of the applied-for license, the Licensee will notify the Authority, within ten days, by certified mail, return receipt requested, of a change in any fact that was reported or required to be reported in connection with this application. Such written notice shall be sent to the following address: New York State Liquor Authority, Director of Licensing, 80 S. Swan St., Suite 900, Albany, NY 12210 / Attention: Out-of-State Direct Shipper’s License Unit VIOLATION OF CONDITIONS OF LICENSURE AS A BASIS FOR REVOCATION AND PENALTIES SHOULD AN OUT-OF-STATE DIRECT SHIPPER’S LICENSE BE GRANTED TO THE APPLICANT, THE FAILURE TO ABIDE BY ANY OF THE CONDITIONS ENUMERATED ABOVE CONSTITUTES A VIOLATION WHICH MAY RESULT IN x THE INSTITUTION OF ADMINISTRATIVE DISCIPLINARY PROCEEDINGS TO SUSPEND OR REVOKE THE OUTOF-STATE DIRECT SHIPPER’S LICENSE, AND TO IMPOSE AN ADMINISTRATIVE FINE OF UP TO TEN THOUSAND DOLLARS. x THE FILING OF A REPORT THAT A VIOLATION HAS BEEN COMMITTED WITH THE TAX AND TRADE BUREAU (TTB) OF THE UNITED STATES DEPARTMENT OF THE TREASURY WITH A REQUEST THAT THE APPLICANT’S BASIC PERMIT BE SUSPENDED OR REVOKED. American LegalNet, Inc. www.FormsWorkflow.com Application for a New York State New York State Division of Alcoholic Beverage Control State Liquor Authority Out-of-State Direct Shipper’s License Alcoholic Beverage Control Law § 79-c – (Calendar Year) (Page 7 of 7) [OSDSL 02 (8-24-05)] THE FOLLOWING CERTIFICATION MUST BE SIGNED AND DATED BY AN INDIVIDUAL APPLICANT OR BY EACH MEMBER OF A PARTNERSHIP THE UNDERSIGNED, EACH FOR HIMSELF/HERSELF, CERTIFIES THAT HE/SHE IS THE APPLICANT ABOVE NAMED; THAT HE/SHE KNOWS THE CONTENTS OF THE ABOVE APPLICATION AND THE STATEMENTS CONTAINED THEREIN AND THE SAME ARE TRUE OF HIS/HER OWN KNOWLEDGE. THE APPLICANT UNDERSTANDS THAT THE STATE LIQUOR AUTHORITY WILL RELY ON EACH AND EVERY ANSWER IN THE APPLICATION AND ACCOMPANYING PAPERS IN REACHING ITS DETERMINATION, AND AFFIRMS THAT ALL STATEMENTS THEREIN ARE TRUE. THE UNDERSIGNED CERTIFIES THE HE/SHE HAS READ THE CONDITIONS FOR THE LICENSE APPLIED FOR AND AGREES TO COMPLY WITH THESE CONDITIONS. (Signature of Individual Applicant or of Each Partner) (Residence) (Home Telephone) (Dated) THE FOLLOWING CERTIFICATION MUST BE SIGNED AND DATED BY AN AUTHORIZED OFFICER OF A CORPORATION CERTIFIES THE HE/SHE IS (Name of Authorized Corporate Officer) (Title) OF THE ABOVE NAMED APPLICANT CORPORATION; THAT HE/SHE KNOWS THE CONTENTS OF THE ABOVE APPLICATION AND THE STATEMENTS AND ANSWERS THEREIN; THAT THE SAME ARE TRUE OF HIS/HER OWN KNOWLEDGE; THAT HE/SHE HAS BEEN AUTHORIZED, BY ORDER OF THE BOARD OF DIRECTORS OF SAID APPLICATION CORPORATION TO MAKE THE STATEMENTS AND ANSWERS IN THIS APPLICATION ON BEHALF OF SAID CORPORATION WITH THE SAME FORCE AND EFFECT AS IF SAID CORPORATION MADE SUCH STATEMENTS AND ANSWERS ITSELF. THE APPLICANT UNDERSTANDS THAT THE STATE LIQUOR AUTHORITY WILL RELY ON EACH AND EVERY ANSWER IN THE APPLICATION AND ACCOMPANYING PAPERS IN REACHING ITS DETERMINATION, AND AFFIRMS THAT ALL STATEMENTS THEREIN ARE TRUE. THE UNDERSIGNED CERTIFIES THE HE/SHE HAS READ THE CONDITIONS FOR THE LICENSE APPLIED FOR AND AGREES TO COMPLY WITH THESE CONDITIONS. (Signature of Authorized Corporate Officer) (Residence Street Address) (City, Town, Village) (Zip Code) (Home Telephone) (Dated) MAIL APPLICATION TO: NEW YORK STATE LIQUOR AUTHORITY DIRECTOR OF LICENSING 80 S. SWAN ST., SUITE 900 ALBANY, NEW YORK 12210 ATTENTION: OUT-OF-STATE DIRECT SHIPPER’S LICENSE UNIT Telephone: (518) 408-2895 American LegalNet, Inc. www.FormsWorkflow.com