Brewer Importer Certification Of A Wholesaler Territorial Coverage
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Brewer Importer Certification Of A Wholesaler Territorial Coverage Form. This is a Wyoming form and can be use in Wyoming Liquor Commission Statewide.
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Tags: Brewer Importer Certification Of A Wholesaler Territorial Coverage, WLD-035, Wyoming Statewide, Wyoming Liquor Commission
WLD-035 (7/02)
Department of Revenue
AREA CODE (307)
AGENT 777-6453
PHONE 777-7233
ADMINISTRATION FAX 777-6255
Website http://revenue.state.wy.us
Liquor Division
The State of Wyoming
1520 East 5th Street, Cheyenne, Wyoming 82002-0110
BREWER/IMPORTER CERTIFICATION OF A WHOLESALER TERRITORIAL COVERAGE
(NOTE: Please prepare a separate statement for each wholesaler representing your brewery in the state of Wyoming.)
In accordance with Section 12-2-201(b) of the Wyoming Statutes, the undersigned brewery representative certifies that the malt beverage wholesaler listed below is authorized to distribute
brands shown in the designated geographical area.
Date:
/
Doing Business As:
Name of Brewery or Importer:
City:
Address:
/
State:
Telephone Number:
Contact Name:
Wholesaler Assigned to Distribute Products:
Zip:
Doing Business As:
DATE ASSIGNED
BRANDS MARKETED
TERRITORIAL/DISTRIBUTION AREA
(Please list distribution areas by county or portions of counties, if possible)
If additional space needed, attach similar format sheets.
This assignment supersedes previous territorial assignment.
As a representative of the brewery/importer named, I verify that the foregoing information is true to the best of my knowledge and represents a true statement of the
distribution areas for our products in the state of Wyoming.
Printed Name
Signature:
Title:
Phone: (
)
FAX:
(
)
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