20___ STATE OF Vermont Department of Liquor Control APPLICATION FOR LICENSE TO MANUFACTURE OR RECTIFY MALT, VINOUS, OR SPIRITOUS BEVERAGES IN VERMONT License Year: May 1st through April 30th the following year. Print Full Name of Person, Partnership, Corp. or LLC Circle One: Malt Vinous $250.00 $250.00 Spirits $250.00 Street & number of premises covered by application Make check payable to and mail to: Vermont Department of Liquor Control Green Mountain Drive, Drawer 20 Montpelier, Vermont 05620-4501 Town or City & Zip Code Telephone Number Mailing Address (if different from above) To the Liquor Control Board, Montpelier, Vermont Application is hereby made for a license to manufacture or rectify malt, vinous, or spirituous beverages under and in accordance with Title 7 of the Vermont Statutes Annotated, as amended, and certify that all statements, information and answers to questions herein contained are true; and in consideration of such license being granted do promise and agree to comply with all local and state laws; and to comply with all regulations made and promulgated by the Liquor Control Board to allow the Liquor Control Board, and any of their assistants and investigators, to examine at any time the premises, supply of beverages, records and papers in reference thereto; to keep such records as the Liquor Control Board may require; and not have any direct or indirect financial interest in any person holding a Vermont first, second or third class license, wholesale dealer’s or bottler’s license, and, upon hearing, the Liquor Control Board may, in its discretion, suspend or revoke such license whenever it may determine that the law or regulations of the Liquor Control Board have been violated, or that any statement, information or answers herein contained are false. Are you applying as (circle one): INDIVIDUAL PARTNERSHIP CORPORATION LLC Please fill name, address, social security number, date and place of birth of individual, partners, or directors, members and stockholders. NAME ADDRESS PLACE OF BIRTH Are all the above citizens of the United States and residents of VERMONT? Yes If naturalized citizens please fill out the following: Name Court where naturalized Location (city, state/zip) OFFICE No Date (Note: Resident Alien is not considered a U.S. citizen) Have any of the above persons been convicted or pled guilty to any criminal or motor vehicles offense in any court of law? Yes No If yes, please attach a sheet explaining the offense, court and date. Are you registered with the Secretary of State to do business in Vermont? corporation chartered in Vermont? If so, give date: Is your corporate charter still valid? If a corporation, is your Corporation Federal ID# Number of Federal Government Basic Permit? Does the applicant understand that he can sell and deliver only to persons within Vermont who hold wholesale dealer or bottler licenses issued by the Vermont Department of Liquor Control? American LegalNet, Inc. www.FormsWorkflow.com The applicant must furnish to the Commissioner of Taxes, Montpelier, Vermont, on or before the 20th day of each month, a report under oath, on a form prescribed and furnished by the Commissioner of Taxes, showing the quantity of malt, vinous, or spirituous beverages sold or delivered to each wholesale dealer within the State of Vermont during the preceding calendar month. ALL APPLICANTS: Describe fully the premises for which this application is made, (i.e., address, type of construction, number of stories, location, etc…). Do you own the premises described? Yes If not, do you lease the premises herein described? No Yes No If premises are leased, name and address of lessor who holds title to property. Please give name, title and date attended of manager, director, partner or individual who has attended a Liquor Control Licensee Education Seminar. Name Title Date (If you have not attended an Education Seminar prior to making applications, please contact your Liquor Control Investigator regarding this mandatory training). I/We hereby certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application (VSA, Title 32, Section 3113). The applicant understands and agrees that the Liquor Control Board many obtain criminal history record information from State and Federal record repositories prior to acting on this application. I/We hereby certify that the information in this application is true and complete. Dated at in the County of State of Vermont, this day of and , 20 (Applicant) (Title) (Signature of member of firm, officer of corporation or authorized agent) American LegalNet, Inc. www.FormsWorkflow.com