Page 1 – Advertisement-Basic-Revised 02/24/05 EXAMPLE OF PUBLIC NOTICE WHEN APPLYING FOR AN ABC LICENSE KRS 243.360 requires a person to first advertise their intention to apply for these licenses in the newspaper. Please use the following to assist you with this requirement. Place your advertisement in the legal section of the newspaper having the largest circulation for the county or city where your premises will be located. YOUR ADVERTISEMENT SHOULD READ AS FOLLOWS: (Fill in the blanks) _________________________________________________________________________________, Mailing address (List the Name of each individual owner(s) or the name of the Corporation, Ltd, or L.L.C. the license will be issued under) ________________________________________________________________________ Hereby declares intention(s) (Include Street, City, State and Zip) to apply for a _____________________________________________________________________________license(s) (List all license types you are applying for. (Example) Retail Beer, Retail Liquor by the Drink, Retail Liquor by the Package, Restaurant Liquor by the Drink, Restaurant Wine by the Drink, Alcoholic Beverage Caterer's, Retailer's Liquor Drink Sampling, Retailer's Liquor Package Sampling, Alcoholic Beverage Limited Restaurant by the Drink, Alcoholic Beverage Golf by the Drink, and so on…) (Be sure to refer to your ABC Schedule form for a complete list of all the license types you are making application for.) no later than ______________________________________________________, The business to be licensed will be (Enter the date you intend to make application to the State ABC) located at _______________________________________________________________ Kentucky _______________. (List the EXACT street address and city where the ABC license is to be issued) (Zip) doing business as ________________________________________________________________________________ (List the name of your business (D.B.A.)) The (owner(s); Principal Officers and Directors; Limited Partners; or Members) are as follows: _____________________, Title or position _____________________, Title or position _____________________, Title or position _____________________, Title or position _____________________, Title or position _____________________, ________________________ of ____________________________________________ Name Home address, city, state and zip code ________________________ of ____________________________________________ Name Home address, city, state and zip code ________________________ of ____________________________________________ Name Home address, city, state and zip code ________________________ of ____________________________________________ Name Home address, city, state and zip code ________________________ of ____________________________________________ Name Home address, city, state and zip code ________________________ of ____________________________________________ Any person, association, corporation, or body politic may protest the granting of the license(s) by writing the Department of Alcoholic Beverage Control, 1003 Twilight Trail, Frankfort, Ky. 40601-8400, within 30 days of the date of this legal publication. (End of advertisement) Forward a clipping of this advertisement along with the Affidavit of Publication to: Kentucky Office of Alcoholic Beverage Control 1003 Twilight Trail Frankfort, Kentucky 40601-8400 (502) 564-4850 phone (502) 564-1442) fax American LegalNet, Inc. www.FormsWorkflow.com Page 2 – Advertisement Rev. 02/24/2005 Commonwealth of Kentucky Office of Alcoholic Beverage Control 1003 Twilight Trail Frankfort, Kentucky 40601-8400 (502) 564-4850 phone (502) 564-1442 fax GLUE OR TAPE CLIPPING HERE AFFIDAVIT OF PUBLICATION Attesting Publication of Intention to Engage in an Alcoholic Beverage Business The following Affidavit of Publication is to be executed by an officer of the newspaper in which the application advertised, one time before the date of application for an alcoholic beverage license, his/her intention to engage in the business authorized by the license(s) applied for. A clipping of the advertisement must be attached to this Affidavit of Publication. _____________________________________________________________of ________________________________ (Name of Officer at Newspaper) (City) (State) Being first duly sworn, says that he / she is __________________________________________________________ (Title of Position at Paper) of the _____________________________________________________ a newspaper printed and published in the (Name of Newspaper) State of ___________County of _________________________, and having a general circulation in the County of ______________________________, Kentucky, and that the attached advertisement is a true copy and has been Published in said newspaper on the following date(s): ________________________________________________ Signature of Officer _____________________________________________ Subscribed and sworn to before me, a Notary Public within and for the State and County aforesaid, by ____________________________ to me personally known, this __________day of _________ (year) _________ My Commission expires the _________day of ________________________________________ (year) _________ County of ________________________ Notary Public ___________________________________________ THIS AFFIDAVIT PROPERLY EXECUTED MUST BE ATTACHED TO THE ABC APPLICATION FOR LICENSING. American LegalNet, Inc. www.FormsWorkflow.com LEASE AGREEMENT I, (We) ____________________________________________________, hereby agree to lease to ___________________________________________, the premises located at ____________________________________________, ____________________________________________, in _________________________County, Kentucky. The said lease shall be for a term of _____________________________, beginning _____________________and ending _________________________. The rent shall be payable at a rate of ____________________________. I understand and agree upon, that the premises herein named shall be used for lawful purposes only. Lessor X_____________________________ Lessor X_____________________________ Lessee X_____________________________ Lessee X_____________________________ Subscribed and sworn to before me, a Notary Public, on this the _______ day of ___________________________, 20_______, by the above Lessor and Lessee. Notary Public __________________________ My commission expires _____________________________________________. American LegalNet, Inc. www.FormsWorkflow.com ABC Edu. Fin. Asst. Self-Certification 12/20/05 SELF-CERTIFICATION FOR COMPLIANCE WITH KRS 164.772 Default in repayment obligation under financial assistance program – Professional licensing and certification – Notification. This form must be completed (signed and dated) by all persons interested in this application, including, but not limited to, officers, partners, and managing members. If this involves more than one person, make copies in order that each such interested person completes this form. Certification of Repayment of Educational Financial Assistance I, _______________________________________________, am an applicant for a license related to alcohol or alcoholic beverages issued by the Kentucky Office of Alcoholic Beverage Control. I hereby certify that I am not in default of a repayment obligation, such as a student loan repayment, under any financial program administered by the Kentucky Higher Education Assistance Authority (KHEAA). ________________________________________ Signature of applicant _____________________ Date RETURN THIS COMPLETED FORM TO STATE ABC ALONG WITH YOUR APPLICATION American LegalNet, Inc. www.FormsWorkflow.com COMMONWEALTH OF KENTUCKY Page 1 ABC Basic application 01/01/07 Site I.D. # OFFICE OF ALCOHOLIC BEVERAGE CONTROL 1003 Twilight Trail Frankfort, Kentucky 40601-8400 502.564.4850 phone 502.564.1442 fax “BASIC APPLICATION FOR ALCOHOLIC BEVERAGE LICENSES” Applications may be returned if all questions are not answered completely. Leave Blank – For ABC Use Only License # __________________ $______________ Val._______________ License #__________________ $______________ Val. ____________ License # __________________ $______________ Val._______________ License# __________________ $______________ Val. ____________ Malt Beverage Administrator’s Approval _________________________________________________________________ Date _____________________ Distilled Spirits Administrator’s Approval _________________________________________________________________ Date ____________________ (A) 1. Applicant’s name(s) or company to be licensed _________________________________________ DBA (Name of Business) _______________________________________________________________ (B). 2. Tax numbers (must be issued in the applicant’s name). Address of premises to be licensed _______________________________________________________ Ky. Sales & Use Tax # _____________ City ______________________ County _____________ State ________ 9 digit zip code ____________ Ky. Withholding Tax # ______________ Mailing address if different from above ____________________________________________________ Contact person 8:00 am – 4:30 pm _____________________e-mail address _____________________ Ky. Corporate Tax # _______________ Contact phone___________________Fax__________________Premises phone __________________ Federal EIN #_____________________ List all ABC Schedule(s) you have attached ___________________ Fee enclosed $________________ (C) 3. 4. 5. List all types of licenses you are applying for _______________________________________________________________________________ What Month do you want your license(s) to become effective? _________________________________________________________________ Describe the type of business you will operate and list how you will sell alcoholic beverages. _________________________________________ Check all that apply: Beer: By the drink only, By the package only, Both by the drink and package. Wine Distilled Spirits: By the drink only, By the package only, Both by the drink and package. 6. Are you the owner of the real estate where these premises are to be licensed?......................................................................................⃞Yes ⃞No If no, you must attach a signed copy of your lease. ABC will not issue or renew any license(s) unless this lease extends through the full period of your license expiration date. List the name of the owner of the premises real estate____________________________________________ Give date lease expires____________ H W F SOCIAL SECURITY NUMBER TITLE DATE OF BIRTH % OF OWNERSHIP ALL PHONE NUMBERS H = HOME W = WORK F = FAX 0 = OTHER LIST DATE & STATE WHERE YOU RESIDED IN PAST 5 YRS. NAME AND ADDRESS USA CITIZEN (D) 7. Complete the following for the business proprietor, partner(s) and all persons interested in the business to be licensed. List all owners, officers, directors, partners, managing members, members, and shareholders (unless publicly held). Show 100% of the ownership. If additional space is needed, please make an attachment. ⃞ Yes ⃞ No % O H W F ⃞ Yes ⃞ No % O H W F ⃞ Yes ⃞ No % O Please state in section D7 if this is a publicly held company. American LegalNet, Inc. www.FormsWorkflow.com Page 2 ABC Basic application 01/01/07 Site I.D. # (E) 8. Is the applicant a corporation, limited partnership, or limited liability company, in good standing with the Ky. Secretary of State?......⃞Yes ⃞No List the State Incorporated or organized in _______________________________________________________________________ Attach a copy of your Articles of Incorporation or Articles of Organization. If incorporated or organized in another state, attach a Certificate of Authority to do business in Kentucky. 9. Is the entire license fee paid by the applicant and by no other person?....................................................................................................⃞Yes ⃞No 10. Are the premises to be licensed located within an incorporated city or town?...........................................................................................⃞Yes ⃞No If yes, list the name of the city or town __________________________________________________________________________ 11. Have you ever been licensed to sell alcoholic beverages?........................................................................................................................⃞Yes ⃞No If yes, give the name of the state and license number(s) ____________________________________________________________ If in Kentucky, are you transferring this license to a new location?............................................................................................................⃞Yes ⃞No 12. Does anyone named in section D 7 of this application have any interest in any kind of alcoholic beverage business or the premises of any alcoholic beverage business other than that for which you are herein applying?............................................................................⃞Yes ⃞No If yes, describe the interest(s) _________________________________________________________________________________ 13. Has the applicant or any person named in section D 7 been convicted of any felony in the past five (5) years or been convicted of a misdemeanor directly or indirectly related to alcohol or a controlled substance within the past two (2) years?.........................................⃞Yes ⃞No If yes, you must attach a statement giving a full explanation, including date(s) of conviction(s). 14. Has a license been suspended or revoked or denied for the premises to be licensed or any person named in section D7 of this Application herein? If yes, attach a statement giving a full explanation, including dates of suspension, revocation, or denial...................⃞Yes ⃞No 15. Are the premises to be licensed and the entrance located on the street level?..........................................................................................⃞Yes ⃞No If no, is the business a hotel, club or restaurant?........................................................................................................................................⃞Yes ⃞No 16. a. Have the premises applied for been licensed to sell alcoholic beverages in the past twelve months?...............................................⃞Yes ⃞No b. c. d. Are the premises currently licensed?...................................................................................................................................................⃞Yes ⃞No If yes, give the Kentucky License number (s) __________________________________________________________________ Is the license being transferred to you?...............................................................................................................................................⃞Yes ⃞No e. Are you acquiring an interest in the existing business?.......................................................................................................................⃞Yes ⃞No If yes, check all the following boxes that apply to you. ⃞ Inventory ⃞ Ownership by purchase of assets ⃞ Leases ⃞ Fixtures and Equipment ⃞ Ownership by purchase of shares ⃞ Other _______________________________________________ (F) 17. THE SELLER SHOULD COMPLETE THIS SECTION IF ITEM # 16 HAS BEEN ANSWERED “YES” OR IF SOMEONE IS TRANSFERRING THEIR LICENSE (S) TO YOU. I (we), _____________________________________________________________________________the seller(s) or owner(s) of the business known (Enter the exact name(s) that appears on the current license(s) as_______________________________________ located at ______________________________________________ Kentucky, am the holder of a ⃞ Malt Beverage (beer) ⃞ Liquor by Drink ⃞ Liquor by Package ⃞ ____________ (other) license(s). The license number(s) is (are) ___________________________. I hereby represent that I have agreed to convey all license privileges (permitted by law) to _____________________________________________________________. I (we) understand that I (we) may not relinquish control of the business, (Enter the exact name(s) that is applying to become the new licensee) premises, or my interest in the licenses until such time as the buyer’s application has been approved by the Office of Alcoholic Beverage Control. Signature of Seller __________________________________________________________________ Title _________________ Date __________ (If a partnership, all partners must sign. If a corporation, only one officer must sign) Sworn or affirmed before me on this ____________ day of _________, year of _________. My Commission expires __________________________ Notary Public ___________________________________________________ County of ___________________ State of ______________________ (Canadian applicants are exempt from this notary requirement) (G) 18. AFFIDAVIT OF BUYER OR NEW PERSON APPLYING FOR THE ABC LICENSE (S) I, __(print your name here)___________________________________________________), do hereby swear or affirm that all statements contained in this application and all its attachments are true and correct to the best of my knowledge, information and belief. I further agree that I shall not engage in any activity involving alcoholic beverages at the premises described herein until I have been issued the appropriate license(s) by the Office of Alcoholic Beverage Control. Once the license(s) is issued, I hereby swear or affirm that I shall abide by all state and local statutes, regulations, and ordinances relating to the manufacture, sale, use, and trafficking in alcoholic beverages. Signature of Buyer or New Applicant __________________________________________ Title ______________________ Date _______________ Sworn or affirmed before me on this _________ day of ______________, year of ____________. My Commission expires _____________________ Notary Public _________________________________________ County of ________________________________ State of ___________________ (Canadian applicants are exempt from this notary requirement) American LegalNet, Inc. www.FormsWorkflow.com Page 1 – Schedule M 01/01/07 (A). Site I.D. # SCHEDULE “M” MANUFACTURER AND PRODUCER LICENSE Applicant’s name(s) or company to be licensed ____________________________________________________________ D.B.A. (Name of Business) _________________________________________________________________________________ Address of premises to be licensed __________________________________________________________________________ (B). 1. Are you applying for a Microbrewery license?.…………...............……………………………………⃞ Yes ⃞ No If yes, KRS 243.157 limits your production to a maximum of 25,000 barrels per year. 2. Are you applying for a Brewer license?.....…….…………………………………………..……………..⃞ Yes ⃞ No If yes, KRS 243.400 requires that a $1,000 surety bond be provided per location. Is your surety bond attached? (See Bond Example).…..……………………....…………………………⃞ Yes ⃞ No 3. Are you applying for a Brew-on-premises license? …………………………………………………….⃞ Yes ⃞ No If yes, 804 KAR 4:340 requires your premises to be located in a wet territory. 4. Are you applying for one of the following licenses? (Check b the license that applies to you) ⃞ Distiller ⃞ Rectifier ⃞ Bottling House ⃞ Vintner If yes, KRS 243.400 requires a $1,000 surety bond be provided per location. Is your surety bond attached?.....................................…………………………………………………...⃞ Yes ⃞ No 5. Are you a licensed Kentucky Distiller who is applying for a Souvenir package liquor license? ⃞ Yes ⃞ No If yes, under KRS 243.0305 will you have a gift shop or other retail outlet at your distillery? ⃞ Yes ⃞ No Are the premises located in wet territory? ……………………………………………….........………… ⃞ Yes ⃞ No 6. Are you applying for a Distiller’s sampling license?…………………………………........………… ⃞ Yes ⃞ No If yes, under KRS 244.050 requires you to be a holder of an active Kentucky Distiller’s License and Souvenir Package Liquor License. List your Kentucky Distiller’s License Number. ____________________________________. List your Kentucky Souvenir Package Liquor License Number . _______________________. 7. Are you applying for a Blender’s license?………………………………………….......……………… ⃞ Yes ⃞ No If yes, KRS 243.140 limits your production to less than 5,000 barrels annually. 8. Are you applying for a Small farm winery license under KRS 243.155? ………………………… ⃞ Yes ⃞ No (a). If yes, how many gallons of wine do you produce annually?..................................................... ___________ Attach copies of the report forms filed by the applicant pursuant to 27 C.F.R. 24.300(g), for the prior two years). If you are a new winery list the date you begin production.____________________. (b). Have you attached a copy of your Federal (TTB) Alcohol, Tobacco Tax and Trade Bureau license to this application?...........................................................................................................⃞ Yes ⃞ No (c). In what state will you operate your small farm winery? _____________________. If not in Ky., attach a copy of your alcohol license from the state your winery is located. 9. Are you applying for a Small farm winery off-premises retail outlet license?..…....................... ⃞ Yes ⃞ No If yes, will your premises be located in wet territory? .........................................................................⃞ Yes ⃞ No List the address of the small farm winery off-premises retail outlet to be licensed. _____________ ______________________________________________________________________________. American LegalNet, Inc. www.FormsWorkflow.com Page 2 – Schedule - M 01/01/07 Site ID # (C). KRS 243.360 requires an applicant to first advertise their intention to apply for these licenses in the newspaper. Please use the attached example to assist you with this requirement. Place your advertisement once in the legal section of the newspaper having the largest circulation for the county where your premises will be located. KRS 424.120 and 424.130(1)(b) describes qualified newspapers. (Small farm winery and small farm winery off-premises retail outlet applicants must advertise in the Kentucky newspaper of highest circulation. (KRS 244.155(1)). After your advertisement has appeared in the paper, obtain a clipping from the paper and attach the Affidavit of Publication to your ABC application. The Affidavit of Publication is enclosed and should be completed by an official of the newspaper where the advertisement appeared. (D). I do hereby solemnly swear or affirm that all statements contained in this application and all attachments are true and correct to the best of my knowledge, information and belief. I incorporate this schedule into my ABC Basic application for a Kentucky alcoholic beverage license. I understand I may not begin to operate with alcohol activity until the Kentucky ABC Office has issued my license(s). I further swear or affirm I shall abide by all state and local statutes, regulations, and ordinances relating to the manufacture, sale, use or and trafficking in alcoholic beverages. Signature of Applicant ___________________________Title _______________Date ___________ Do not complete this Section (E) if you are applying for a (E). Small farm winery license or Small farm winery off-premises retail outlet license. OBTAIN SIGNATURE OF LOCAL ABC ADMINISTRATOR'S APPROVAL Your Local ABC Administrator must approve this application before it is forwarded to the State ABC. Take or mail this application schedule, the ABC Basic application, fee and all attachments to your Local ABC Administrator. Obtain their signature of approval below or make arrangements for this approval to be sent to the State ABC Office in Frankfort, Kentucky. This certifies that the applicant(s) herein above named have been approved for the types of license applied for and for the premises above specified. SIGNATURE OF APPROVAL OF LOCAL ABC ADMINISTRATOR ________________________________Date ______________ ⃞ City of ______________________________Administrator (or) the ⃞ County of ____________________________Administrator ________________________________________________________________________________________ (F). You may now forward this application schedule, the ABC Basic application, all attachments, and your state license fee to: KENTUCKY OFFICE OF ALCOHOLIC BEVERAGE CONTROL 1003 Twilight Trail Frankfort, Kentucky 40601-8400 Telephone 502-564-4850 Fax 502-564-1442 American LegalNet, Inc. www.FormsWorkflow.com Page 3 – Schedule - M 01/01/07 TYPES OF LICENSE & FEES Site I.D. # Check a the boxes for the type(s) of license(s) you are applying for. To determine the ABC license fee(s), find the license type(s) In the left column, then move right across the table. Licenses issued 6 months or more pay a full year fee. Licensees issued less than 6 months pay one-half year fee. Attach a certified check, cashier check, or a money order. Make payable to: KENTUCKY STATE TREASURER WE DO NOT ACCEPT CASH! PREFIX LICENSE TYPE BLENDER ⃞ BREWER ⃞ DISTILLER ⃞ RECTIFIER ⃞ KRS 243.140 KRS 243.250 KRS 243.120 KRS 243.130 KRS 243.400 KRS 243.120 KRS 243.130 KRS 243.400 BL a ⃞ KRS 243. 035, 243.400 & 804 KAR 4:040 BREW ON PREMISES MICROBREWERY ⃞ KRS 243.157 SOUVENIR LIQUOR PACKAGE FOR DISTILLERS ⃞ ⃞ 1,000.00 500.00 500.00 250.00 100.00 50.00 25.00 12.50 KRS 243.157 ⃞ 804 KAR 4:340 VT 1,250.00 ⃞ ⃞ 2,500.00 ⃞ BH SPECIAL VINTNER ⃞ DT HALF YEAR FEE Pay this amount ⃞ RT BOTTLING HOUSE ⃞ MB FULL YEAR FEE Pay this amount BOP MIC ⃞ SLP ⃞ KRS 243.0305 SMALL FARM WINERY ⃞ DISTILERS SAMPLING ⃞ KRS 243.155 ⃞ ⃞ KRS 244.050(2) SMALL FARM WINERY OFF-PREMISES RETAIL OUTLET ⃞ KRS 243.155 SFW DSL SFWOP ⃞ ⃞ TOTALS American LegalNet, Inc. www.FormsWorkflow.com Page 4-Schedule – M 01/01/07 CHECK LIST Site ID # 1. Have you attached a certified check, cashier check or money order, payable to: Ky. State Treasurer for your License fees and a separate check for your Kentucky Background checks? No Cash! ⃞Yes ⃞ No 2. Have the buyer and seller (if applicable) signed and had this application notarized? ⃞Yes ⃞ No 3. Have you answered each question fully and checked the type(s) of license(s) you are applying for? ⃞Yes ⃞ No 4. Have you signed your application(s) and had your signature notarized? ⃞Yes ⃞ No 5. Have you secured the signature of approval from your local ABC Administrator on this application? ⃞Yes ⃞No ⃞N/A 6. Have you attached a certified copy of your newspaper advertisement for this license? ⃞Yes ⃞No ⃞N/A 7. Have you attached articles of incorporation, partnership papers, or other organizational papers? ⃞Yes ⃞No ⃞N/A 8. Have you attached a signed copy of your lease that does not expire before your license expires? ⃞Yes ⃞No ⃞N/A 9. If applying for a Brewer, Distiller, Rectifier, Bottling House or Vintner License, Have you attached a copy of your surety bond? ⃞Yes ⃞No ⃞N/A 10. If you are requesting approval for Brands of Distilled Spirits and or Wines have you completed and attached ABC Form 715? ⃞Yes ⃞No ⃞N/A 11. If you are requesting approval for Brands of Malt Beverages (Beer) have you completed and attached ABC Form 714? ⃞Yes ⃞No ⃞N/A 12. If you are applying for a Small farm winery license have you attached a copy of your Federal TTB license and proof of production? KRS 243.155 requires a Small farm wineries produce less than 50,000 gallons of wine annually. ⃞Yes ⃞No ⃞N/A FORWARDING YOUR APPLICATION TO THE KENTUCKY ABC OFFICE You may now forward this application schedule, ABC Basic application, all attachments, and your state license fee to: Commonwealth of Kentucky Office of Alcoholic Beverage Control 1003 Twilight Trail Frankfort, Kentucky 40601-8400 Telephone (502) 564-4850 Fax (502) 564-1442 American LegalNet, Inc. www.FormsWorkflow.com (Bond) 01/01/07 Site ID # COMMONWEALTH OF KENTUCKY Office of Alcoholic Beverage Control 1003 Twilight Trail Frankfort, Kentucky 40601-8400 Telephone (502) 564-4850 Fax (502) 564-1442 DISTILLED SPIRITS, WINE AND MALT BEVERAGE TAX BOND Name of Applicant ___________________________________________________________________ Address __________________________________________________County __________________ Having filed an application to engage in the business of trafficking in distilled spirits and wine in accordance with the Alcoholic Beverage Control Laws Acts of the 1983 General Assembly of Kentucky, as amended, now we, __________________________, Principal and __________________________ Surety, of (name of Surety) ____________________________________________________hereby bind ourselves in the sum of ___________________________dollars, that the said Principal will pay to the Commonwealth of Kentucky, the amount of tax and penalties and interest for which the said Principal may become liable. This bond shall not be binding on either Principal or Surety unless the license applied for and for which this bond is required to issue to the Principal upon proper authority of the Commonwealth of Kentucky, and shall be subject to cancellation upon sixty (60) days written notice by the Principal, Surety or proper authority of the Commonwealth of Kentucky. This bond shall expire on ____________________________________. Witness our hand this ___________day of __________________________________, ____________. Signature of Principal ___________________________________________________ Date ________. Signature of Surety _____________________________________________________ Date ________. All applicants for a Brewer, Distiller, Rectifier, Blender, Vintner, Wholesaler or Non-Resident Licensee Permit must execute a bond and submit the application for a License. The amount of the bond to be determined by the Office of Alcoholic Beverage Control and the Kentucky Revenue Cabinet under (KRS 243.400 and KRS 243.410.) American LegalNet, Inc. www.FormsWorkflow.com ABC Form 715 Distilled Spirits and Wine Brand Registration Page 1 of 2 01/01/07 DISTILLED SPIRITS AND WINE BRAND REGISTRATION Commonwealth of Kentucky Office of Alcoholic Beverage Control 1003 Twilight Trail Frankfort, Kentucky 40601-8400 Phone (502) 564-4850 Fax (502) 564-1442 http://abc.ky.gov In compliance with KRS 244.440, we hereby register our brands listed herein, which will be distributed by the following named Kentucky Wholesalers: 1. Supplier (Company Name)_______________________________(Phone) _____________(Fax) ____________ 2. Supplier Complete Address ___________________________________________________________________ 3. Supplier’s Federal Permit Number _________________________(Contact Person) ______________________ 4. Authorized Signature of Supplier _______________________________________Date ___________________ 5. Kentucky Wholesaler Name _______________________________(Phone)_____________(Fax) ___________ 6. Wholesaler’s Complete Address _______________________________________________________________ 7. Wholesaler’s Federal Permit Number _______________________(Contact Person) _____________________ 8. Authorized Signature of Wholesaler __________________________________Date ______________________ 9. Name of Brands (Please print clearly one Brand per line) (Include all current approved brands and new brands being added.) LIST ALL CURRENT & NEW BRANDS LIST ALL CURRENT & NEW BRANDS • • • • • • • • • • • • • • • • • • • • SUBMIT OR FAX ONE COPY TO (502) 564-1442. ABC will send the Kentucky Wholesaler this copy after its approval. Do not include Distilled Spirits and Wine Labels or BATF Label documentation. SUPERSEDES FILE NUMBER EFFECTIVE DATE THIS FILE NUMBER American LegalNet, Inc. www.FormsWorkflow.com ABC Form 715 Distilled Spirits and Wine Brand Registration Page 2 of 2 01/01/07 LIST ALL CURRENT & NEW BRANDS LIST ALL CURRENT & NEW BRANDS • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • American LegalNet, Inc. www.FormsWorkflow.com ABC Form 714 Beer Brand Registration Page 1 of 2 01/01/07 MALT BEVERAGE BREWER BRAND APPROVAL AND DISTRIBUTOR TERRITORIAL DESIGNATION AGREEMENT IN KENTUCKY Commonwealth of Kentucky Office of Alcoholic Beverage Control 1003 Twilight Trail Frankfort, Kentucky 40601-8400 Telephone (502) 564-4850 Fax (502) 564-1442 hppt//:abc.ky.gov A SEPARATE FORM MUST BE MADE FOR EACH BRAND IF HANDLED IN MORE THAN ONE TERRITORY BY DIFFERENT BEER DISTRIBUTORS. THIS FORM MAY BE REPRODUCED IF NECESSARY. SUBMIT TO THE KENTUCKY ABC DEPARTMENT YOUR REQUEST FOR APPROVAL NO LATER THAN 20 DAYS PRIOR TO THE INTRODUCTION OF A NEW BRAND IN KENTUCKY OR ANY CHANGES IN CURRENT AGREEMENTS. 1. BREWER NAME ______________________________________________________________________________ ADDRESS ______________________________________________________________________________ TELEPHONE # ___________________________________________ FAX #_____________________________ CONTACT PERSON (print name)_______________________________TITLE _____________________________ 2. SUPPLIER INFORMATION: check one (1). Are you the importer or the master distributor for this brand(s)? COMPANY NAME _____________________________________________________________________________ ADDRESS _____________________________________________________________________________ TELEPHONE # ___________________________________________ FAX #____________________________ CONTACT PERSON (print name)________________________________TITLE ___________________________ LICENSE NUMBER ___________________________________________. 3. KENTUCKY BEER DISTRIBUTOR’S NAME________________________________________________________ ADDRESS ____________________________________________________________________________ TELEPHONE # ___________________________________________ FAX #___________________________ CONTACT PERSON (print name)________________________________TITLE ___________________________ LICENSE NUMBER ___________________________________________. CONTINUED ON PAGE (2) TWO American LegalNet, Inc. www.FormsWorkflow.com ABC Form 714 Beer Brand Registration Page 2 of 2 01/01/07 MALT BEVERAGE BREWER BRAND APPROVAL AND DISTRIBUTOR TERRITORIAL DESIGNATION AGREEMENT IN KENTUCKY PAGE TWO OF TWO 4. BRAND INFORMATION: List the brand(s) of malt beverages to be distributed by the Kentucky Distributor listed in # 3 of this form. _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Are these brands of malt beverages currently assigned, or have been recently assigned, to any other Kentucky Beer Distributor for the same territory? ………………………………………………………………………………………………………………………..….……….⃞ Yes ⃞ No If yes, you MUST obtain the signature of the Kentucky Beer Distributor this agreement will replace in #6 of this form. 5. TERRITORY INFORMATION: Describe the assigned territory: 6. SIGNATURES: Signature of Brewer: ______________________________________Title ___________________Date ____________ Print name of person signing: _______________________________ Signature of Importer or Master Supplier (if applicable): ______________________________Title __________________ Date ____________ Print name of person signing: _______________________________ Signature of Kentucky Beer Distributor: ______________________Title ___________________Date ___________ Print name of person signing: ________________________________ Signature of Distributor being replaced By this agreement (if applicable): ____________________________Title ___________________Date __________ Print name of person signing: _________________________________Kentucky ABC License # _________________ American LegalNet, Inc. www.FormsWorkflow.com