Print Form American LegalNet, Inc. www.FormsWorkFlow.com 3. Have you EVER had a criminal conviction in any state or foreign jurisdiction? YES NO 5. Are you familiar with Arizona State Liquor Laws and Regulations? YES NO 6. Do you agree to notify the Department of Liquor of any proposed change of ownership or other changes prior to making any such changes? YES NO 7. Do you agree to keep all records, invoices, and other documents relating to the purchase, sale, or delivery of spirituous liquor for a period of two years and to have them easily accessible for examination? YES NO 8. Do you consent to an investigation of your background including all records of every kind and description including police records and to waive any rights or causes of action that you may have against the Department of Liquor Licenses and Control and any other individual or agency disclosing or releasing said information to the Department? YES NO 4. If you answered 'YES' to questions 1, 2, or 3, give complete details: (Attach additional sheets if necessary) 9. If you answered 'NO' to any of questions 5, 6, 7, or 8 give complete details: (Attach additional sheets if necessary) FALSE OR INCOMPLETE ANSWERS COULD RESULT IN THE DENIAL OR SUBSEQUENT REVOCATION OF A LICENSE OR PERMIT. SECTION 6 WHOLESALER INFORMATION 1. Provide the names and addresses of the wholesalers licensed in this state through which you will ship spirituous liquor into this state. (Attach a separate sheet) 2. Provide the names and addresses of each wholesaler in this state who has received shipments from you within the previous three years and the number of shipments to each. (Attach separate sheet) IMPORTANT NOTICE The “Direct Shipment License” allows the shipment of alcohol into the State of Arizona, to an Arizona licensed Wholesaler ONLY. (You may Not ship directly to an individual) Arrangements will need to be made with the Wholesaler to sell your product to an Arizona licensed retailer. The retailer will then be responsible for the delivery of the alcohol to the individual customers. I, , hereby declare that I am the APPLICANT filing this (Print Name) application. I have read this application and the contents and all statements are true, correct and complete. I acknowledge that shipments into this state contrary to Section 4-203.04 will result in the immediate suspension of the Direct Shipment License. State of X County of The foregoing instrument was acknowledged before me this (Signature) day of Day , Month Year My commission expires on: Signature of NOTARY PUBLIC American LegalNet, Inc. www.FormsWorkFlow.com ARIZONA DEPARTMENT OF LIQUOR LICENSES & CONTROL 400 W Congress #150 Tucson AZ 85701-1352 (520) 628-6595 800 W Washington 5th Floor Phoenix AZ 85007-2934 (602) 542-5141 DIRECT SHIPMENT LICENSE (INFORMATION) LIQUOR REGULATIONS AND PROHIBITIONS (A.R.S. § 4-203.04) Direct shipment license: issuance: fee: requirements: penalties: cease and desist orders: violation: classification A. The Director may issue a direct shipment license to an out-of-state person who is engaged in business as a distiller, vintner, brewer, rectifier, blender or other producer of spirituous liquor if the person is licensed in the state where the person’s principal place of business is located and the director determines that the person is capable and reliable and is qualified to hold a direct shipment license. B. A person shall apply for a Direct Shipment License on a form prescribed by the Director. The Director may charge an application fee. In addition to other matters required by the Director, an application for a direct shipment license shall include: 1. The address of the out-of-state premises where the applicant’s principal place of business is located and a copy of the applicant’s spirituous liquor license in that state. 2. The name, address and telephone number of an officer of the applicant who is authorized to represent the applicant before the Director. 3. A complete and full disclosure by the applicant and by any officer, director, administrator or controlling person of the applicant of any criminal convictions in any state or foreign jurisdiction within the five years immediately preceding the application. 4. The names and addresses of the wholesalers licensed in this state through which the applicant will ship spirituous liquor into this state. 5. The number of individual orders of spirituous liquor, if any, that the applicant shipped to wholesalers in this state during the previous three years and the names and addresses of each wholesaler who received the shipments. 6. A statement that the applicant acknowledges that shipments by the applicant of spirituous liquor into this state contrary to this section will result in the immediate suspension of the applicant’s direct shipment license. C. The Director may refuse to issue a license for good cause. After a hearing, the Director may suspend or revoke a Direct Shipment License for good cause. The Director shall not issue a Direct Shipment License to any person who: 1. Has had a direct shipment license or any license to deal in spirituous liquor revoked in this state or any other state within one year preceding the application. 2. Has been convicted of a felony in this state or any other state or has been convicted of an offense in another state that would be a felony if convicted in this state within five years preceding the application. (Continued on back) Disabled individuals requiring special accommodations please call (602) 542-9027 American LegalNet, Inc. www.FormsWorkFlow.com D. A Direct Shipment License is valid for three years. Direct Shipment Licenses may not be renewed or transferred. A person who holds a Direct Shipment License may apply for a new license not more than ninety days before expiration of the person’s current license. E. A resident of this state who is twenty-one years of age or older may place an order for spirituous liquor for the person’s own personal use with an out-of-state person who holds a Direct Shipment License in person, by telephone, mail or catalog or on the Internet. F. A person who holds a Direct Shipment License shall ensure that shipments of spirituous liquor pursuant to this section are made in conformance with all applicable provisions of this title and rules adopted pursuant to this title. A Direct Shipment Licensee who violates this title or rules adopted pursuant to this title is subject to a fine. A civil or criminal penalty and suspension or revocation of the person’s license. G. A person who holds a Direct Shipment License shall deliver spirituous liquor ordered pursuant to subsection E of this section to a wholesaler who is licensed in this state. The wholesaler shall pay all luxury taxes imposed on the shipment pursuant to Title 42, Chapter 3 to the Department of Revenue and shall deliver the liquor to a retailer with off-sale privileges who is licensed in this state. H. The licensed retailer shall deliver the spirituous liquor or shall arrange for the delivery of the spirituous liquor to the person who placed the order and shall collect and pay to the Department of Revenue all transaction privilege taxes imposed pursuant to Title 42, Chapter 5. The retailer shall: 1. Ensure that: (a) The person making the delivery is twenty-one years of age or older. (b) The delivery occurs only during the hours that spirituous liquor may be lawfully served in this state. (c) Deliveries are not made to persons who are obviously intoxicated or are otherwise disorderly.. (d) The person accepting the delivery is twenty-one years of age or older and exhibits an acceptable written instrument of identification pursuant to section 4-421. 2. Make a record of the delivery at the time of delivery on a form approved by the Director of the Department of Liquor Licenses and Control. The record shall be retained by the retailer for at least two years and shall include the following information: (a) The business name, address and license number of the retailer. (b) The date and time of delivery. (c) The address where the delivery occurred. (d) The type, brand and amount of the spirituous liquor delivered. (e) The printed name and signature of the person making the delivery. (f) The printed name and signature of the person accepting the delivery, along with the type and serial number of the written identification the person accepting delivery presented. (g) The age of the person accepting delivery. 3. Refuse to complete a delivery if the retailer believes that the delivery would violate any applicable provision of this title. I. If the Director has reasonable cause to believe that a person who is licensed pursuant to this section is acting in violation of this section, the Director may serve a cease and desist order requiring the person to cease and desist the violation. The Director may impose a civil penalty of not more than one hundred fifty thousand dollars against a person who knowingly violates a cease and desist order issued pursuant to this section. J. Section 4-201 does not apply to licenses issued pursuant to this section. American LegalNet, Inc. www.FormsWorkFlow.com