STATE OF INDIANA ALCOHOL AND TOBACCO COMMISSION 302 West Washington Street IGCS Room E114 Indianapolis, IN 46204 Telephone 317 / 232-2430 Fax 317 / 233-6114 www.IN.gov/atc SUPPLEMENT FOR MICRO-WHOLESALER’S PERMIT APPLICATION The applicant, ___________________________, seeks a Micro-Wholesaler’s Permit under Indiana Code 7.1-4-4.1-13(c). The applicant certifies that he or she has never previously held a wine wholesaler’s permit and anticipates selling less than twelve thousand (12,000) gallons of wine and brandy in a year or previously held a wine wholesaler’s permit and certifies to the commission that the permit applicant sold less than twelve thousand (12,000) gallons of wine and brandy in the previous year. I certify that this supplement was completed by myself and that any attachments are true and correct. I UNDERSTAND THAT IT IS A FELONY TO MISREPRESENT OR FALSIFY ANY PORTION OF THIS APPLICATION OR ATTACHED DOCUMENTS. __________________________________________________ Signature of Applicant _______________________ Date (month, day, year) Name of Applicant _______________________________________________________________ Doing Business as (d/b/a): ________________________________________________________ Address: ______________________________________________________________________ ______________________________________________________________________________ Telephone Number: _____________________________________________________________ State Form 54363 (9-10) American LegalNet, Inc. www.FormsWorkFlow.com