WLD-29 (4/18) 6601 Campstool Road Cheyenne, Wyoming 82002 - 0110 Manufacturer/Rectifier or Importer License Application License fee: $250.00 LICENSING TERM: From: to License #: Type of License Importer Manufacturer Rectifier Applicant: D/B/A : Premise Address: City: State: Zip: Mailing Address: City: State: Zip: Business Phone: Business Fax: Contact Person: List states in which you are or have previously been licensed as a manufacturer/rectifier or importer. STATE DATES Is this business a new enterprise? YES NO Have you submitted a copy of the Federal Basic Permit? YES NO Have you registered with the Dept of Treasury, Alcohol and Tobacco Tax and Trade Bureau? (TTB.GOV) YES NO FILING AS (CHOOSE ONLY ONE) I NDIVIDUAL (SOLE PROPRIATOR) CORPORATION LLC LLP Is the licensed premises: O wned Leased Rented If the premises is leased, please provide a copy of the lease. / / $ Cash Recpt #: Check Ck #: Processed by: Payment Processed: / / Control Number: American LegalNet, Inc. www.FormsWorkFlow.com WLD-29 (4/18) If applicant is an Individual(s) or Partnership: State the name, date of birth and residence of the applicant and of each applicant or partner, if the application is made by more than one individual or partnership. True and Correct Name Date of Birth DO NOT LIST PO BOXES Residence Address, Street, City, State & Zip Residence Phone Number Have you been a DOMICILED resident for at least 1 year and not claimed residence in any other State in the last year? Do you hold any interest, directly or indirectly, in any liquor license or permit issued in the State of Wyoming? Have you been Convicted of a Violation Relating to the sale or manufacture of Alcoholic Liquor or Malt Beverages? YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO (If more information is required, complete in identical form, on a separate piece of paper and attach to this application.) If the applicant is a Corporation, Limited Liability Company, Limited Liability Partnership or Limited Partnership: State the name, date of birth and residence of each stockholder holding, either jointly or severally, ten percent (10%) or more of the outstanding and issued capital stock of the corporation, limited liability company, limited liability partnership, or limited partnership, and every officer, and every director. True and Correct Name Date of Birth DO NOT LIST PO BOXES Residence Address, Street, City, State & Zip Residence Phone Number No of years in corp or LLC % of Stock Held Do you hold any interest, directly or indirectly, in any liquor license or permit issued in the State of Wyoming? Have you been Convicted of a Violation Relating to the sale or manufacture of Alcoholic Liquor or Malt Beverages? YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO (If more information is required, complete in identical form, on a separate piece of paper and attach to this application.) American LegalNet, Inc. www.FormsWorkFlow.com WLD-29 (4/18) List all products which you propose to import, manufacture or rectify within the State of Wyoming. Product Brand Name Description (If more information is required, complete in identical form, on a separate piece of paper and attach to this application.) Please note, any changes in product (addition or discontinuance), change or label, etc require written notification to the Wyoming Liquor Division. VERIFICATION AND ACKNOWLEDGEMENT By submission of this application, the applicant hereby agrees that: a) All applicable state and federal laws will be adhered to; b) All applicable state excise taxes will be timely reported and paid; c) Signature indicates that applicant has examined this application, including accompanying statement, and to the best of d) Requires all signatures for individual and partnership, 1 signature for an LLC and 2 signatures for corporations. STATE OF WYOMING ) SS. COUNTY OF ) Before Me, ,(specify) a Notary Public/Officer authorized to administer oaths in (Printed name of Notary or other officer authorized to administer oaths) and for County, State of Wyoming, Personally appeared (Insert Names) and he/she being first duly sworn by me upon his oath, says that the facts alleged in the foregoing instrument are true. (Seal) My commission expires: 1. 2. 3. 4. Witness my hand and official seal: Dated: (Notary public or other officer authorized to administer oaths) Please mail $250.00 check, application and (Title) a copy of your Federal Basic Permit to: Wyoming Liquor Division Compliance 6601 Campstool Rd. Cheyenne, WY 82002-0110 American LegalNet, Inc. www.FormsWorkFlow.com