APPLICATION FOR TWO-YEAR AGENT’S PERMIT, AGENT’S BEER LICENSE AND MANUFACTURER’S AGENT’S PERMIT TABC USE ONLY FIRST READ ALL INSTRUCTIONS TYPE OR PRINT IN INK FORM L-104 (9/2011) ISSUE DATE FEE SURCHARGE LATE FEE (RENEWAL ONLY) A BK T 1A. APPLICATION FILED FOR: A AGENT’S PERMIT BK AGENT’S BEER LICENSE T MANUFACTURER’S AGENT’S PERMIT B. APPLICATION FILED FOR: Original Renewal Change Registry No. Change of: FOR ALL AGENTS Notification of New Employer C. If renewal or change, enter License/Permit No(s).: A- BK- T- FOR AGENT 2. Social Security Number - Issuing State and Driver’s License Number Date of Birth (mm/dd/yyyy) / / Full Legal Name (Last, First, Middle) 3. Permanent Mailing Address City 4. Area Code + Business Telephone Number ) ( County Area Code + Alternate Telephone Number ( ) - State Zip Code (9 digits) - E-mail Address (optional) FOR EMPLOYER(S) 5. List the name(s) and address(es) of employer(s). (If more space is needed, attach additional page). The person whose name and address appears in Question 2 is hereby designated as our authorized agent. Street Address: Street Address: City, County, State, Zip Code: City, County, State, Zip Code: Permit/License Number of Wholesaler/Distributor: Permit/License Number of Wholesaler/Distributor: Signature of authorized representative of employer: SIGN HERE: FOR EMPLOYER(S) Name of Firm: Signature of authorized representative of employer: TABC USE ONLY Name of Firm: SIGN HERE: FOR TABC USE ONLY WRITTEN PROCESS DATE / END PROCESS DATE / / / Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR TWO-YEAR AGENT’S PERMIT, AGENT’S BEER LICENSE AND MANUFACTURER’S AGENT’S PERMIT CONTINUED FORM L-104 (9/2011) SIGN AND NOTARIZE ALL AGENTS 7. 8. Has applicant been convicted of a felony or any provision of the Alcoholic Beverage Code or any rule of the Texas Alcoholic Beverage Commission? If “YES,” specify: Does the applicant or anyone with whom applicant is residentially domiciled have any interest directly or indirectly in the finances, premises, business, equipment or fixtures of a permittee or licensee of a different level in this state? If “YES,” specify: 9. Has applicant loaned, given, or furnished any money, service or any other thing of value to any retailer in this State? If “YES,” specify: 7. YES NO 8. YES NO 9. YES NO WARNING: Section 101.69 of the Texas Alcoholic Beverage Code is as follows: “…a person who makes a false statement or false representation in an application for a permit or license or in a statement, report, or other instrument to be filed with the Commission and required to be sworn commits an offense punishable by imprisonment in the penitentiary for not less than 2 nor more than 10 years.” ACKNOWLEDGMENT PRINT NAME: NAME MUST APPEAR AS NAME SHOWN IN QUESTION 2 SIGN HERE: SIGNATURE MUST APPEAR AS NAME SHOWN IN QUESTION 2 Before me, the undersigned authority, on this day of , 20 the person whose name is signed to the foregoing application personally appeared and, duly sworn by me, states under oath that he or she read the said application and that all the facts therein set forth are true and correct. SIGN HERE: NOTARY PUBLIC (S E A L) ALL AGENTS INSTRUCTIONS 1. BEGINNING OCTOBER 1, 2008 ALL AGENT’S LICENSES/PERMITS WILL BE ISSUED FOR A TWO-YEAR PERIOD. You MUST renew for the entire two-year period. The total amount of fees plus surcharges to cover the two-year period MUST be paid at the time of renewal. Fees may NOT be prorated or refunded. 2. Prepare the application in duplicate. Send the original application with the proper fee and surcharge to the Texas Alcoholic Beverage Commission, P.O. Box 13127, Austin, Texas, 78711. Keep duplicate for your files. 3. Fees and surcharges must be paid with Cashier’s Check, Money Order, or Firm Check from a corporate permittee made payable to the Comptroller of Public Accounts. We will not accept personal checks. The fees and surcharges are shown below: *Surcharge Class of Permit or License Annual State Fee Total Due Effective 9/01/11 Agent’s Permit $20.00 $94.00 $114.00 Agent’s Beer License $20.00 $94.00 $114.00 Manufacturer’s Agent’s Permit $20.00 $94.00 $114.00 *SURCHARGE SUBJECT TO ANNUAL CHANGE 3. *Surcharges are subject to annual change. The surcharges assessed each year are determined by the Texas Alcoholic Beverage Commission and not by the Legislature. The Legislature determines the total dollar amount to be raised in agency revenue. The revenue is comprised of fees, which are set by the Legislature, and the surcharges which are determined by the agency. 4. ENSURE YOUR EMPLOYER(S) HAS (HAVE) SIGNED THE APPLICATION IN THE SPACE(S) PROVIDED IN QUESTION 5. THE EMPLOYER MUST HOLD A VALID LICENSE/PERMIT ISSUED BY THE TEXAS ALCOHOLIC BEVERAGE COMMISSION OR MUST BE IN THE PROCESS OF APPLYING FOR SUCH. 5. If applying for both Agent’s Beer License and Agent’s Permit, the license number of the Distributor and permit number of the Wholesaler must be shown. Applicants for a Manufacturer’s Agent’s Permit must indicate Nonresident Seller’s Permit number. 6. You may not hold both a Manufacturer’s Agent’s Permit and Agent’s Permit. 7. All licenses and permits expire 2 years from issue date. 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