State of California EDMUND G. BROWN JR., Governor Department of Alcoholic Beverage Control MALT BEVERAGE LABEL FILING APPLICATION Submit this form to the Department of ABC, Attn: Price Posting, 3927 Lennane Drive, Suite 100, Sacramento, CA 95834. Include labels attached to a separate sheet of paper (no photocopies or size reductions ). Also include an endorsed copy of your fictitious business name statement, if applicable. (See additional instructions, ABC-412 Instr.) 1. MANUFACTURER'S LEGAL NAME 2. CALIFORNIA ABC LICENSE NUMBER Pending 3. MANUFACTURER'S ADDRESS (Street number and name, city, state, zip code) 4. CERTIFICATE OF COMPLIANCE NUMBER 5. CONTACT PERSON'S NAME 6. CONTACT PHONE NUMBER Pending 7. IS THE MANUFACTURER OF THE PRODUCT DIFFERENT FROM THE SHIPPER Yes No If Yes, complete questions #8-11. If No, skip to question #12. 8. SHIPPER'S NAME (As appears on Bill of Lading as Consignor) 9. SHIPPER'S ADDRESS (Street number and name, city, state, zip code) 10. CONTACT PERSON'S NAME 11. CONTACT PHONE NUMBER 12. IS PRODUCT CONTRACT BREWED? Yes No If Yes, complete questions #13-17. If No, skip to question #18. 13. CONTRACTOR'S NAME 14. IF IN CA, LICENSE NUMBER Pending 15. CONTRACTOR'S ADDRESS (Street number and name, city, state, zip code) 16. CONTACT PERSON'S NAME 17. CONTACT PHONE NUMBER 18. IS MANUFACTURER USING A FICTITIOUS BUSINESS NAME ON LABEL? Yes No If Yes, complete questions #19-20. If No, skip to question #21. 19. FICTITIOUS BUSINESS NAME 20. HAS FICTITIOUS BUSINESS NAME STATEMENT BEEN FILED PREVIOUSLY WITH ABC? Yes No 21. IS THIS PRODUCT REQUIRED TO BE LABELED PURSUANT TO SECTION 25205 OF THE ABC ACT? Yes No 22. PRODUCT BRAND(S) SIZE(S) 23. AUTHORIZED SIGNATURE ALCOHOL CONTENT PERCENTAGE (By volume) 24. DATE SIGNED FOR ABC USE ONLY DATE MAILED Label(s) Accepted For Filing Label(s) Rejected For Filing (See attached ABC-412 INSTR) DEPARTMENT SIGNATURE ABC-412 (04/11) American LegalNet, Inc. www.FormsWorkFlow.com