ATT-104 (Rev. 06/19/15) BRAND AND LABEL REGISTRATION AND DESIGNATION OF SALES TERRITORY FORM Notice To ensure timely processing of your brand and label registration application, please review the following information: · Forms are available online at http://dor.ga.gov/documents/forms (select Alcohol & Tobacco). · Application for Brand and Label Registration and Designation of Sales Territory - Form ATT-104: Follow the instructions and complete the Application in its entirety. Failure to do so may delay processing of your Application. o Reasons for Submitting: You must check one of the provided options. Please ensure that the correct option has been checked. Please note that the option "To register brands with original license application." should only be chosen for the initial license application. If you already have a license, do not choose this option. o Assigned Territories must be listed in alphabetical order and cannot overlap with another territory. Your chosen distributor should provide a breakdown of locations and territories covered. Only list "Entire State" if distributor has a single location. · Processing Fee: For Distilled Spirits brands and labels, a $10.00 processing fee is required for each item being registered. A processing fee is not required to register Wine or Malt Beverages brands and labels. · Power of Attorney - Form RD-1061: A Power of Attorney is required for any person requesting information on account that was not registered with the initial license application or during the renewal process. The person signing the form cannot be the same person being granted the Power of Attorney. · Letter(s) of Authority/Ownership: Required from all persons involved in the production, bottling, brewing and/ or vinting of the brand being registered if the name on the Certificate of Label Approval (COLA) is not the Importer or the company registering the brand. The Letter must clearly identify the name listed on the label and give Exclusive or Sole authority to register the brand. If claiming a DBA or Trade Name, a Basic Permit must be included to validate the authorized DBA or Trade Name. BRAND AND LABEL REGISTRATION MUST BE SUBMITTED ONLINE AT https://gtc.dor.ga.gov American LegalNet, Inc. www.FormsWorkFlow.com ATT-104 (Rev. 06/19/15) APPLICATION FOR BRAND AND LABEL REGISTRATION AND DESIGNATION OF SALES TERRITORY SUBMITTED BY : ____________________ ____________________ ____________________ SUBMITTED TO : Submit online at https://gtc.dor.ga.gov Georgia Department of Revenue Alcohol & Tobacco Division E-mail: ATDIV@dor.ga.gov Telephone: (404) 417-4900 INSTRUCTIONS 1. 2. 3. 4. Application must be typed or printed. Application must be accompanied by one (1) label and a copy of the Federal Label Approval for each label being registered. Application must be accompanied by a Letter of Authority to register brands if applicant is not the producer. Application must be signed by an officer or owner of the Company registered with the Department of Revenue. Signatures should be legible, or have the name printed below the signature. Stamped signatures are not acceptable. All other signatures require a GA Power of Attorney (Form RD-1061) to be included with each application. The registration fee for Distilled Spirits covers up to ten (10) brands when applying for Distilled Spirits license. To register additional Distilled Spirits brands the processing fee is $10 per item. There is no fee required to register Wine and Malt Beverage brands. 5. THE PROCESSING OF THIS APPLICATION WILL BE DELAYED UNLESS IT IS PROPERLY SIGNED, COMPLETE INFORMATION FURNISHED, AND APPLICABLE QUESTIONS ANSWERED. (FAILURE TO CHOOSE THE CORRECT OPTION COULD DELAY YOUR APPLICATION) REASONS FOR SUBMITTING THIS APPLICATION ( CHECK ONE) To register brand(s) with original license application. (Include with license application and contingent upon issuance of license.) To register brand(s) for special order shipping. To register additional brand(s) and designate sales territory. To designate additional territories for brand(s) previously registered. To re-designate sales territory for brand(s) previously registered to existing wholesaler. To designate a new wholesaler: requires a letter of release from present wholesaler. } A 30 day processing time required by Revenue Regulations This is to certify that a copy of this form has been furnished to the wholesaler or wholesalers as required by Revenue Regulations. ____________________________ SIGNATURE ____________________________ TITLE ___________________________ DATE American LegalNet, Inc. www.FormsWorkFlow.com STATE OF GEORGIA ALCOHOL & TOBACCO DIVISION ATT-104 (Rev. 06/19/15) BRAND/BRAND LABEL(S) REGISTRATION AND DESIGNATION OF SALES TERRITORY LEGAL NAME D/B/A STI NUMBER/LICENSE NUMBER ADDRESS CITY STATE ZIP CODE NAME OF DESIGNATED GEORGIA WHOLESALER (IF APPLICABLE) GEORGIA DISTRIBUTOR LICENSE NUMBER ADDRESS CITY STATE ZIP CODE [ ] Malt Beverage [ ] Wine [ ] Distilled Spirits % OF ALCOHOL CONTENT BY VOLUME [ ] Wine Special Order Shipping ASSIGNED TERRITORIES (LIST IN ALPHABETICAL ORDER) *N/A For Wine Special Order Shipping Only Only List "Entire State" If Distributor Has A Single Location FULL BRAND / BRAND LABEL NAME LIST IN ALPHABETICAL ORDER 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. BRAND(S) / BRAND LABEL(S) HAVE BEEN PREVIOUSLY SHIPPED TO A WHOLESALE DISTRIBUTOR IN THE STATE OF GEORGIA. N/A NO YES: LIST THE SHIPPER AND WHOLESALE DISTRIBUTOR(S) 1. IF APPLICANT IS NOT THE PRODUCER OF THE BRAND(S), THE REGISTRATION MUST BE ACCOMPANIED BY A CERTIFICATE OF AUTHORITY FROM THE PRODUCER OF EACH BRAND BEING REGISTERED GIVING THE APPLICANT EXCLUSIVE RIGHTS TO DISTRIBUTE THESE BRAND(S). (EXCLUDES WINE SPECIAL ORDER SHIPPING). THE PRODUCER IS DETERMINED BY NAME INDICATED ON LABEL. 2. A SEPARATE FORM MUST BE COMPLETED FOR EACH GEORGIA DISTRIBUTOR BEING DESIGNATED BY A SUPPLIER WITH A SEPARATE REGISTRATION FOR EACH WAREHOUSE LOCATION. (EXCLUDES WINE SPECIAL ORDER SHIPPING). SIGNATURE TITLE DATE SIGNATURE MUST BE MADE BY AN OWNER OR OFFICER OF THE COMPANY REGISTERED WITH THE DEPARTMENT OF REVENUE. ALL OTHER SIGNATURES REQUIRE A POWER OF ATTORNEY AUTHORIZATION TO BE COMPLETED ON FORM RD-1061. American LegalNet, Inc. www.FormsWorkFlow.com