Domestic Foarm Winery Or Domestoc Mecrobrewery Manufacturing Report
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Domestic Foarm Winery Or Domestoc Mecrobrewery Manufacturing Report Form. This is a Arizona form and can be use in Liquor Licenses And Control Statewide.
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ARIZONA DEPARTMENT OF LIQUOR LICENSES & CONTROL
800 W Washington 5th Floor
Phoenix AZ 85007-2934
www.azliquor.gov
(602) 542-5141
DOMESTIC FARM WINERY OR DOMESTIC MICROBREWERY MANUFACTURING REPORT
ARS §4-205.04 (B) Please check report type and year that applies to your liquor license
Domestic Farm Winery - Fiscal Year: July 1– June 30, __________
(Year)
Domestic Microbrewery - Calendar Year: Jan. 1– Dec. 31, _________
(Year)
1. Licensee’s Name: _______________________________________________________
First (or business on liquor license)
Last
2. Liquor License Number: __________________________________________________
3. Licensee/Agent Name: ___________________________________________________
First
Last
4. License Address Location: ________________________________________________________
5. Amount of Wine Manufactured (in Gallons) _______________________
6. Amount of Beer Manufactured (in Gallons) _______________________
Reporting party must be an agent, manager or authorized owner listed on the Arizona Department of
Liquor Licenses and Control records for the Domestic Farm Winery or Domestic Microbrewery.
I, ___________________________________________, declare that the content and statements in this document is true, correct and complete.
(Print name)
X________________________________________________
State of __________________County of __________________
The foregoing instrument was acknowledged before me this
(Signature)
My commission expires on: _____________________________
_________ day of ____________________, ________
Day
Month
Year
_____________________________________
(Signature of NOTARY PUBLIC)
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