Ohio Department of Commerce Division of Liquor Control, Beer and Wine Section 6606 Tussing Road, P.O. Box 4005 Reynoldsburg, Ohio 43068-9005 (614) 644-2411 Fax (614) 644-2480 http://www.com.ohio.gov/liqr Division Use Only Reg. Date: Check No. Amount $ New Label _____ of _____ Application for Product/Label Registration Please Print Legibly or Type: Company Name: Company Address: City: Check here if this is a new mailing address Telephone Number: Contact Person: Type of Application: Ohio Supplier/Permit #: Email/Phone: State: Dba: See Page 2 "Specific Instructions / Document Checklist" for additional documents that MUST accompany your application Zip Code: New Product/Label - $50.00 Filing Fee - Allow 30-45 business days for processing Label Revision - No Fee Previous Approval Date: or - No Fee New Size Container - Previous Approval Date (required) Answer questions 1-6 below: 1. Brand Name (REQUIRED): 2. Varietal or Type: 3. Fanciful Name (if any): 4. Appellation (wine only): 5. Identify the Alcoholic Beverage Classification: (REQUIRED) Mixed Beverage: Beer: Wine: List the Alcoholic Content: % alcohol by volume: 6. Are you registering a brand recently acquired from another company? YES NO If YES, provide the name of former company: PLEASE AFFIX ONE COMPLETE SET OF LABELS BELOW ­ (if necessary use separate sheet) I hereby declare the above information is true and correct. Print Name: Signature: ____________________________________________________ DLC 1511 Rev. (3/30/2015) 1-800-750-0750 Title: Date: ___________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com An Equal Opportunity Employer and Service Provider TTY Users Dial ORS SPECIFIC INSTRUCTIONS / DOCUMENT CHECKLIST FOR PRODUCT / LABEL REGISTRATION Your application may be returned if you do not comply with or submit the following: Name, address, telephone # and contact person Enter the company name and current mailing address. A telephone number and/or email address must appear on the application in case any clarification is needed. The application MUST be executed and filed by the person, firm, or corporation that will bottle or import the beer, malt beverage, wine, or mixed beverage. Check the appropriate box: "New" or "Revision." Filing of Application Type of Application Alcohol Content Provide the alcohol content for all product types (Item #5). Alcohol content for all product types MUST be shown as % of alcohol by volume. Federal Certificate of Label Approval (COLA) from the U.S. Department of Treasury, Alcohol and Tobacco Tax and Trade Bureau (TTB) MUST be submitted for all applicable products. This form is required to designate a wholesale distributor and specify the exclusive sales territory for all products registered by a manufacturer or supplier. If the applicant is also the holder of an S permit issued by the State of Ohio, and will not sell its products through an Ohio wholesale distributor, it is not necessary to submit this territory designation form. If the applicant is importing a product for a foreign or domestic (US) manufacturer, submit a letter from the manufacturer appointing the applicant as their importer or designated agent. Glue one complete set of labels for which approval is requested to the front of this application. If the labels are on can flats or on some other material for which gluing is impractical, affix one photo or electronic image to the application. Provide a $50.00 registration fee in the form of a company check, cashier's check or money order, made payable to the Division of Liquor Control for each product/label registered with the Division of Liquor Control . Federal Certificate Territory Designation (DLC 1539) Supplier Appointment Letter Label Information - MUST accommodate Supplier Application DLC1551 Fee Structure Please complete this application in its entirety and attach all supporting documentation in order to avoid having your application returned. If you have any questions please contact 614-644-2411. Submit your completed application, accompanying documents, and fee(s) to the: Ohio Division of Liquor Control Attn: Beer and Wine Section 6606 Tussing Road P.O. Box 4005 Reynoldsburg, OH 43068-9005 American LegalNet, Inc. www.FormsWorkFlow.com