APPLICATION FOR NONRESIDENT SELLER’S PERMIT, NONRESIDENT BREWER’S PERMIT AND NONRESIDENT MANUFACTURER’S LICENSE TABC USE ONLY FIRST READ ALL INSTRUCTIONS TYPE OR PRINT IN INK FORM L-103 (11/2011) ISSUE DATE FEE SURCHARGE LATE FEE (RENEWAL ONLY) S U BS 1A. APPLICATION FILED FOR: S NONRESIDENT SELLER’S PERMIT U NONRESIDENT BREWER’S PERMIT BS NONRESIDENT MANUFACTURER’S LICENSE Registry No. FOR ALL APPLICANTS B. APPLICATION FILED FOR: Original Renewal Change Change of: C. If renewal or change, enter license/permit no(s).: S2. APPLICATION IS FILED BY: Individual Partnership U- BS- Corporation Limited Liability Company Other: Limited Partnership Limited Liability Partnership 3. Trade Name of Business 4. Address or Location City County State 5. Mailing Address State City/Foreign Country 6. Area Code + Business Telephone Number ( ) - Area Code + Alternate Telephone Number ( ) - Zip Code (9 digits) Zip Code (9 digits) - E-mail Address (optional) TABC USE ONLY FOR ALL APPLICANTS FOR INDIVIDUAL FOR INDIVIDUAL Issuing State and Driver’s License Number 7. Social Security Number - Date of Birth (mm/dd/yyyy) / / Full Legal Name (Last, First, Middle) Residential Address City State Zip Code ( 9 Digits ) - ALL APPLICANTS 8. Give name, address, and phone number of appointed agent, resident of Texas, certified by applicant to the Secretary of State at Austin, Texas, as the person upon whom notice of a hearing may be served concerning matters, proceedings, hearings and causes involving the refusal, cancellation or suspension of a permit or license issued by this commission. Name shown here must be the same as that shown on Form L-20.2. Name: Address: Phone Number: ( ) - INITIAL APPLICATION INCOMPLETE YES - NO ADDITIONAL CORRESPONDENCE DATE CROSS CHECKED YES - NO # OF PAGES WRITTEN PROCESS DATE / / END PROCESS DATE / / PROCESSOR I.D. PROCESSOR REVIEW DATE / / CROSS CHECK DATE YES - NO / / PROCESSOR ERROR YES - NO Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com P ARTNERSHIPS/CORPORATIONS TRADE NAME: FORM L-106-PC (8/2005) 1A. Indicate type of ownership and complete the information below: Corporation Limited Liability Company Partnership Limited Partnership Limited Liability Partnership B. Federal Employer’s I.D. No.: C. Entity Name: D. Charter No.: FOR ALL OFFICER(S), PARTNER(S), DIRECTOR(S), MANAGER(S), STOCKHOLDER(S) AND MEMBER(S). Date Approved: E. Number and class of shares, memberships or units issued: / / State: 2. COMPLETE THE FOLLOWING PER INSTRUCTIONS: Social Security Number - Issuing State and Driver’s License Number Full Legal Name (Last, First Middle) Officer Partner Director/ Manager Date of Birth (mm/dd/yyyy) / / Stockholder/ Member Residential Address Social Security Number - Full Legal Name (Last, First Middle) Officer Partner Director/ Manager Date of Birth (mm/dd/yyyy) / / Stockholder/ Member Residential Address Social Security Number - Issuing State and Driver’s License Number Officer Partner Director/ Manager Date of Birth (mm/dd/yyyy) / / Stockholder/ Member Residential Address Full Legal Name (Last, First Middle) Officer Partner Director/ Manager Date of Birth (mm/dd/yyyy) / / Stockholder/ Member Residential Address Social Security Number - Full Legal Name (Last, First Middle) Officer Partner Director/ Manager Date of Birth (mm/dd/yyyy) / / Stockholder/ Member Residential Address Social Security Number - Full Legal Name (Last, First Middle) Residential Address Officer Partner Director/ Manager Date of Birth (mm/dd/yyyy) / / Stockholder/ Member State Zip Code (9 digits) - Class & No. Shares Held or % Memberships or % Interest State Zip Code (9 digits) - Class & No. Shares Held or % Memberships or % Interest State Zip Code (9 digits) - Class & No. Shares Held or % Memberships or % Interest Title City Issuing State and Driver’s License Number Class & No. Shares Held or % Memberships or % Interest Title City Issuing State and Driver’s License Number Zip Code (9 digits) - Title City Issuing State and Driver’s License Number State Title City Full Legal Name (Last, First Middle) Social Security Number - Title City Issuing State and Driver’s License Number Class & No. Shares Held or % Memberships or % Interest State Zip Code (9 digits) - Class & No. Shares Held or % Memberships or % Interest Title City State Zip Code (9 digits) - (IF YOU NEED ADDITIONAL SPACE FOR MORE NAMES, USE ADDITIONAL COPIES OF THIS PAGE) Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com ALL APPLICANTS TRADE NAME: FORM L-103 (11/2011) FOR ALL APPLICANTS ALL APPLICANTS 9. The applicant or permit and license holder may have an interest, directly or indirectly in only one level of the alcoholic beverage industry; i.e. manufacture, wholesale or retail. You or your agent, servant or employee may not: 1. be employed in any capacity at different levels, 2. rent or lease property or equipment from or to an entity operating at another level, 3. secure credit or a loan in any form for an entity at another level, 4. control in any fashion the interests of a permittee or licensee at a different level. A. Are you or anyone indicated in questions 7 on L-103 or 2 on L-106-PC in violation of the above requirements? 9A. YES NO If “YES,” explain below: (If more space is needed, attach a page.) FOR NONRESIDENT SELLER’S PERMIT FOR NONRESIDENT MANUFACTURER’S LICENSE FOR NONRESIDENT SELLER’S PERMIT NOTE: Section 37.10(a) and (b) provides: “ No holder of a nonresident seller’s permit may solicit, accept, or fill an order for distilled spirits or wine from a holder of any type of wholesaler’s permit unless the nonresident seller is the primary source for the brand of distilled spirits or wine that is ordered. In this section, “primary American source of supply” means the distiller, the producer, the owner of the commodity at the time it becomes a marketable product, the bottler, or the exclusive agent of any of those. To be the “primary American source of supply” the nonresident seller must be the first source, that is the manufacturer or the source closest to the manufacturer, in the channel of commerce from whom the product can be secured by American wholesalers.” NOTE: IF APPLYING FOR A NONRESIDENT BREWER’S PERMIT AND/OR NONRESIDENT MANUFACTURER’S 10. Is the applicant “the primary American source of supply” for any brands of distilled spirits or wine within the meaning of Section 37.10(a) and (b) of the Texas Alcoholic Beverage Code? If “YES,” specify the manufacturer and brands of distilled spirits and/or wine. (If more space is needed, attach a page.) 10. YES NO NONRESIDENT BREWER’S PERMIT FOR NONRESIDENT MANUFACTURER’S LICENSE LICENSE, EACH LOCATION WHERE PRODUCT IS MANUFACTURED AND SHIPPED INTO THIS STATE MUST APPLY FOR AND OBTAIN A PERMIT OR LICENSE. 11A. Will the applicant actually engage in the business of brewing and packaging beer within a three year period covered by its original license and two successive renewals thereof in such quantities as will make its operation that of a bona fide brewing manufacturer? 11A. YES NO B. Is applicant the actual manufacturer of the beer to be imported into the State of Texas? B. YES NO C. Is location in question 4 the actual manufacturing location of the product being shipped into Texas? If answer is “NO,” application cannot be approved. C. YES NO D. YES NO 12. YES NO D. Will the applicant transport beer into Texas in vehicles owned or leased by applicant? If answer is “YES,” refer to #4 of the instructions shown on page 4 for necessary bond requirement. FOR NONRESIDENT BREWER’S PERMIT 12. Is location in question 4 the actual manufacturing location of the product being shipped into Texas? If answer is “NO,” application cannot be approved. Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com ACKNOWLEDGMENT TRADE NAME: FORM L-103 (11/2011) ACKNOWLEDGMENT 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 If Applicant is: Individual Who Must Sign: PRINT NAME: Individual Owner Partnership Partner Corporation Officer Limited Partnership General Partner Limited Liability Company Officer or Manager SIGNATURE MUST APPEAR AS NAME SHOWN IN QUESTION 7 ON L-103 OR 2 ON L-106-PC. Before me, the undersigned authority, on this General Partner Limited Liability Partnership NAME MUST APPEAR AS NAME SHOWN IN QUESTION 7 ON L-103 OR 2 ON L-106-PC. SIGN HERE: 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) INSTRUCTIONS INSTRUCTIONS 1. Beginning September 1, 2009 the license covered under this form 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. Mail the original application to the Texas Alcoholic Beverage Commission, P.O. Box 13127, Austin, Texas 78711 with the correct license/permit fees, surcharges and bond (if required). Keep duplicate for your files. 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. *Surcharge Class of Permit or License Annual State Fee Total Due Effective 9/01/11 Nonresident Seller’s Permit $300.00 $376.00 $676.00 Nonresident Brewer’s Permit $3,000.00 $376.00 $3,376.00 Nonresident Manufacturer’s License $1,500.00 $576.00 $2,076.00 *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. A Power of Attorney designating Service Agent on Form L-20.2 must be mailed directly to the Secretary of State of Texas. Only a Texas resident, 18 years or older, may be appointed as Service Agent. The power of attorney designating Service Agent should indicate the individual named in question 8 on L-103. 5. Any Nonresident Manufacturer desiring to transport beer into this state in vehicles owned or leased by the Nonresident Manufacturer will be required to furnish a tax bond on Form 2-52.5 in the amount of $10,000.00. The tax bond must be submitted prior to transporting the first shipment of beer. The bond must be executed by a Surety Company authorized to do business in Texas. 6. If applicant is a partnership, 100% of the interest in the partnership must be accounted for among the partners listed. If one or more of your general or limited partners is a limited partnership or limited liability partnership, complete an additional Form L-106-PC for each partnership. If one or more of your general or limited partners is a corporation, complete Form L-106-PC for each corporation or limited liability company. 7. If applicant is a publicly held corporation, provide pertinent information as indicated in 2 on L-106-PC on all stockholders holding 5% or more of the shares. TABC USE ONLY THE FOLLOWING INFORMATION IS FOR TABC HEADQUARTERS USE ONLY. DO NOT ENTER ANYTHING BELOW THIS BOX NOTE: TAX SECURITY BS – ONLY REQUIRED IF QUESTION 11D IS ANSWERED “YES.” NAME ADDRESS CITY, STATE, ZIP NUMBER TYPE AMOUNT Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com