Applicant: D/B/A : Contact Person: Contact Phone: Company Location: Mailing Address : Business Phone: Business Fax: E - Mail Address: Website: Is the above information correct? Yes No If No, Please update. FILING AS (CHOOSE ONLY ONE) SOLE PROPRIETOR PARTNERSHIP CORPORATION LLC LLP If a corporation, LLC or LLP list the full names and residence address of all the officers and directors and of all shareholders owning jointly or severally ten percent (10%) or more of the stock of the corporation, LLC or LLP. Use back of form if additional space is needed. NAME RESIDENCE ADDRESS DATE OF BIRTH % OF STOCK By filing this application, I agree to operate in Wyoming under the requirements of W.S.12-2-204 and all other applicable Wyoming laws and rules, and to file required monthly tax reporting documents and taxes. If no shipments occur for any given month, the monthly tax report is still required. I understand that violation of these laws and rules may constitute cause for denial, suspension or revocation of my license. State statute requires a copy application can not be processed without the current license. By signing this application, I acknowledge for (Business Name) that all of the information provided is true and correct, and that I agree to meet the Wyoming operating conditions specified above. This application must be signed by an owner, partner, corporate officer or LLC/LLP member. Signature: Title: Date: / / Mail completed application, copy of liquor license and a check for $50.00 made out to: Wyoming Liquor Division Attn: Licensing 6601Campstool Road Cheyenne, WY 82002-0110 6601 Campstool Road, Cheyenne, Wyoming 82002 NEW OUT - OF - STATE WINE SHIPPER LICENSE APPLICATION / / $ Check # Processed by: Payment Processed: / / Control Number: LICENSE FEE: $50.00 LICENSE#: LICENSE TERM: // through June 30, 201 9 American LegalNet, Inc. www.FormsWorkFlow.com