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Application For Out-Of-State Domestic Farm Winery Or Domestic Microbrewery Form. This is a Arizona form and can be use in Liquor Licenses And Control Statewide.
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Tags: Application For Out-Of-State Domestic Farm Winery Or Domestic Microbrewery, Arizona Statewide, Liquor Licenses And Control
ARIZONA DEPARTMENT OF LIQUOR LICENSES & CONTROL
www.azliquor.gov
400 W Congress #521
Tucson AZ 85701-1352
(520) 628-6595
800 W Washington 5th Floor
Phoenix AZ 85007-2934
(602) 542-5141
APPLICATION FOR OUT-OF-STATE DOMESTIC FARM WINERY
OR DOMESTIC MICROBREWERY
SECTION 1 This application is for a:
New License
SECTION 2 Type of ownership:
Domestic Microbrewery
Domestic Farm Winery
DFW produces less than 20,000 gallons annually
Yes
Individual
Partnership
Corporation
LLC
No
_______________ _______________________________________________
Domestic Farm Winery
Name of Individual, Corporation or Partnership
Domestic Microbrewery
Agent Change
SECTION 3 Fees:
DOMESTIC FARM WINERY
DOMESTIC MICROBREWERY
Application Fee:
$100
ISSUANCE FEES: Full year/$200 Half year/$150
ISSUANCE FEES: Full year/$600 Half year/$450
A service fee of $25.00 will be charged for all dishonored checks (A.R.S. 44-6852)
SECTION 4 Applicant:
1. Applicant/Agent's Name:
(Insert one name ONLY to appear on license)
Last
First
Middle
2. Business Name:
(Exactly as it appears on the exterior of premises)
3. Business Address:
(Do not use P.O. Box Number )
City
State
Zip
4. Mailing Address:
(All correspondence will be mailed to this address)
5. Business Phone: (
)
6. Federal ATF Permit #:
City
Residence Phone: (
State
Zip
)
Resident State Liquor License #:
ATTACH A COPY OF YOUR LICENSE THAT PERMITS YOU TO DEAL IN SPIRITUOUS LIQUOR IN YOUR RESIDENT STATE. IF
YOU ARE NOT LICENSED IN YOUR RESIDENT STATE, QUESTIONNAIRES (available on-line) NEED TO BE COMPLETED BY
EACH OWNER, AGENT, PARTNER, STOCKHOLDER (10% OR MORE), MEMBER, OFFICER OR MANAGER. ALSO EACH
PERSON COMPLETING THIS FORM MUST SUBMIT AN “APPLICANT” TYPE FINGERPRINT CARD WHICH MAY BE OBTAINED
AT THE DEPARTMENT OR YOUR LOCAL POLICE DEPARTMENT. THERE IS A PROCESSING FEE OF $29 PER CARD WHICH
MUST ACCOMPANY EACH QUESTIONNAIRE. FINGERPRINTING MUST BE DONE BY A BONA FIDE LAW ENFORCEMENT
AGENCY OR A FINGERPRINTING SERVICE. THE DEPARTMENT DOES NOT PROVIDE THIS SERVICE.
7. Arizona Transaction Privilege Tax # _______________________ (Domestic Farm Wineries Further information available
at www.azdor.gov)
PURSUANT TO ARS §4-205.04, DOMESTIC FARM WINERIES SHALL PAY TO THE ARIZONA DEPARTMENT OF REVENUE ALL LUXURY TAXES
IMPOSED PURSUANT TO TITLE 42, CHAPTER 3 AND ALL TRANSACTION PRIVILEGE OR USE TAXES IMPOSED PURSUANT TO TITLE 42,
CHAPTER 5. DOMESTIC MICROBREWRIES SHALL PAY ALL LUXURY TAXES IMPOSED ON SALES AT RETAIL OR TO LICENSED RETAILERS
PURSUANT TO A.R.S.§ 42-3355(B).
SECTION 5 All questions MUST be answered.
1. Have you EVER had an application for any business license, professional license or liquor license rejected,
YES
denied, suspended, or revoked?
NO
2. Has anyone EVER filed suit or obtained a judgment against you in any Civil action, the subject
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of which involved fraud or misrepresentation involving a liquor license?
3. Have you EVER had a criminal conviction in any state or foreign jurisdiction?
YES
NO
YES NO
4. If you answered 'YES' to questions 1, 2, or 3, give complete details:
(Attach additional sheets if necessary)
5. Are you familiar with Arizona State Liquor Laws and Regulations?
YES
NO
YES
NO
YES
NO
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?
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?
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?
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 OF A LICENSE OR PERMIT.
SECTION 6 WHOLESALER INFORMATION – DOMESTIC FARM WINERY PRODUCING MORE THAN
20,000 GALLONS IN A CALENDAR YEAR OR A DOMESTIC MICROBEWERY
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 Domestic Microbrewery license allows the shipment of alcohol into the State of Arizona to an Arizona licensed
Wholesaler or directly to retailers (if shipments to a retailer do not exceed 93,000 gallons in a calendar year - ARS 4-205.08.D.5.
You may not ship directly to a consumer.)
I,
, hereby declare that I am the Applicant/Agent filing
(Print Name)
this 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
liquor license.
State of
County of
X
The foregoing instrument was acknowledged before this
(Signature)
day of
Day
My commission expires on:
11/2006
,
Month
Year
Signature of NOTARY PUBLIC
Disabled individuals requiring special accommodations please call (602) 542-9027
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