For Official Use Only LBD-01 Rev 9/09 STATE OF CONNECTICUT Department of Consumer Protection Liquor Control Division 165 Capitol Avenue Hartford, CT 06106 Telephone: (860) 713-6200 Web Site: www.ct.gov/dcp APPLICATION FOR BRAND LABEL REGISTRATION INSTRUCTIONS : Please print clearly or type. Complete application and submit to the address above for each brand label to be registered. This application must be accompanied by a check and/or money order made payable to “Treasurer, State of CT." See fee schedule below. Type or print legibly the Company Name and Address Fee Schedule: (fee applies for a 3-year period) Company Name 1). Registrant located in Connecticut: $200.00 per label 2). Registrant located Out-of-State: $200.00 per label 3). Manufacturer located in Connecticut: $15.00 per label Address If the Company Name on the label differs from that of the Registrant, check ( ) the appropriate box for each brand label to be registered. Item No BRAND NAME (as it appears on the label) Unimerc Brand Code DBA or Trade Name Authorized Agent Attach Authorization 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 American LegalNet, Inc. www.FormsWorkFlow.com