DBPR ABT-6018 – Division of Alcoholic Beverages and Tobacco Primary American Source of Supply and Brand/Label Registration Application STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION 1940 North Monroe Street Tallahassee, FL 32399-0783 If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation, at (850) 488-8284. Please send your completed application and required fee(s) to: Department of Business and Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-1021 SECTION 1 - CHECK TRANSACTION REQUESTED Transaction Type for Vinous and Distilled Spirits: Primary American Source (PAS) Initial License Revised Label(s) (Enter brand number(s) in Section 4) Transaction Type for Malt Beverages: Brand/Label Registration Fiscal Year July 1, 20____, through June 30, 20____ “FL/Florida” Imprinting Revised Label(s) (Enter brand number(s) in Section 4) Approval Exemption (Attach Exemption Request) No change since prior approval Exempt (Attach copy of each approval letter) Registrant/PAS Name SECTION 2 - BUSINESS INFORMATION FL Document Number Business Location Address Telephone Number City Fax Number State Zip Code State Zip Code Business Mailing Address City Type of Business: Manufacturer Distributor Importer Other: _______________________________________ 5 American LegalNet, Inc. www.FormsWorkFlow.com SECTION 3 - FLORIDA WHOLESALE DISTRIBUTOR(S) TO WHOM SHIPMENTS WILL BE MADE Registrant License Number Business Name City Signature____________________________________________________________ Date _____________ Title__________________________________________ 6 American LegalNet, Inc. www.FormsWorkFlow.com PRIMARY AMERICAN SOURCE of SUPPY LICENSURE and BRAND/LABEL REGISTRATION APPLICATION SECTION 4 - Enter all required information below (refer to directions on instruction sheet; attach additional sheets if necessary). Brand Number Brand Name Type* Alc. % Vol. Proof Approval Date (Division Use Only) DIVISION USE ONLY ** TYPE: Enter the number code in the “Type” field above: [1] Distilled Spirit [10] Malt [4] Spirits Base Cooler [11] Malt Base Cooler [5] Pre-mixed Cocktail [7] Vinous [8] Wine Base Cooler Container Size(s) Master Number: Receipt Number: [13] Natural Sparkling Wine [15] Cordial Liqueur [16] Liqueur 7 American LegalNet, Inc. www.FormsWorkFlow.com