SCHEDULE “T” TRANSPORTER LICENSE Schedule T 01/01/07 Site I.D. # LEAVE BLANK – FOR ABC USE ONLY License # _____________________________ $ ________________________ Validating Number _____________________________ License # _____________________________ $ ________________________ Validating Number _____________________________ Malt Beverage Administrator’s Approval _______________________________________________ Date ________________________________ Distilled Spirits Administrator’s Approval Date (A) Applicant’s name(s) or company to be licensed ________________________________________________________________________________ DBA (Name of Business) _________________________________________________________________________________________________ Address of premises to be licensed _________________________________________________________________________________________ City _______________________________________________ County __________________ State ____________9 digit zip code ____________ Mailing address if different from above ______________________________________________________________________________________ Telephone ( ) ________________________ Fax ( ) ______________________ Other Phone ( ) __________________________ Enter amount of fee enclosed $ ___________________________ List the type(s) of licenses(s) you are applying for ______________________________________________________________________________ st Enter the date you want this license to become effective (month)___________, (day) _____, (year) _______, through December 31 . (year)_____ ALL PHONE NUMBERS H = HOME W = WORK F = FAX 0 = OTHER SOCIAL SECURITY NUMBER TITLE H W F O ⃞ Yes H W F O ⃞ Yes H W F O ⃞ Yes ⃞ No ⃞ No ⃞ No DATE OF BIRTH % OF OWNERSHIP NAME AND ADDRESS LIST DATE & STATE WHERE YOU RESIDED IN PAST 5 YRS. 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. USA CITIZEN (B) 1. % % % American LegalNet, Inc. www.FormsWorkflow.com Page 2-Schedule - T 01/01/07 (C) 2. SCHEDULE "T" PAGE 2 SITE ID # Are you a commercial airline system, charter flight system, or a commercial cargo system company applying for an Air Transporter License? If yes, under KRS 243.050 (2)(3) list the storage location(s) if operating from more than one airport in Kentucky. ________________________________________________________________________________________. 3. Are you a contract or common carrier for hire applying for a Liquor Transporter License? Yes This license will authorize drop-offs, pick-ups and traveling through Kentucky. If yes, under KRS 243.200 attach a copy of your certificate of authority to transport as a common carrier issued by the Department of Transportation Federal Motor Carrier Safety Administration. 4. Are you an out-of-state distiller, rectifier, vintner, wholesaler or distributor, applying for a Non-Resident Liquor Transporter License? If yes, attach a copy of your certificate of authority to transport as a common carrier issued by the Department of Transportation Federal Motor Carrier Safety Administration. 804 KAR 4:030 requires you to attach a corporate surety bond in the amount of $2,500. Is your bond attached? Yes No No Yes No Yes No 5. Are you applying for a Through Transporter Liquor License? Yes If yes, list your ICC (Interstate Commerce Commission) number issued by the Kentucky Department of Transportation. ________. Attach a copy of your certificate of authority to transport as a common carrier issued by the Department of Transportation Federal Motor Carrier Safety Administration. 804 KAR 4:170 requires a Through Transporter to be a common carrier or a licensed vintner or distiller operating company owned trucks traveling over Kentucky highways. No 6. Are you applying for a Liquor Freight Forwarder License? If yes, 804 KAR 4:180 will allow you to receive, hold, and ship distilled spirits and wine by common carriers who are licensed by this Office. Yes No 7. Are you a contract or common carrier for hire applying for a Malt Beverage (beer) Transporter License? Under KRS 243.210 this license will authorize drop-offs, pick-ups and traveling through Kentucky. If yes, attach a copy of your certificate of authority to transport as a common carrier issued by the Department of Transportation Federal Motor Carrier Safety Administration. Yes No 8. Are you a beer distributor, wholesaler, or licensed transporter applying for a Special Beer Transporter License? Yes No If yes, 804 KAR 4:160 restricts transportation of malt beverages for export only through Kentucky. List the type of license you hold ________________________the state of issuance __________the license number__________. 9. Do you understand that, if granted a license, authorized field representatives of the Ky. ABC Office may stop and examine cargo of any truck or vehicle in which distilled spirits, wine or malt beverages are being transported within the boundaries of the Commonwealth of Kentucky? Yes No 10. Is the entire license fee paid by the applicant and by no other person? Yes No 11. Does anyone named in this application have an 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? If yes, describe the interest(s). _______________________________________________________________. Yes No Yes No Yes No 12. a. Has the applicant or any person named in this application been convicted of any felony? b. Has the applicant or any person named in this application been convicted of a misdemeanor, directly or indirectly, related to alcohol or a controlled substance? If yes, to either question attach a statement giving a full explanation, including dates and convictions. (D) AFFIDAVIT OF PERSON APPLYING FOR THE KENTUCKY 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 Applicant _____________________________________Title __________________________Date ________________________ Sworn or affirmed before me on this _______day of _____, year of ________. My commission expires _____________________________ Notary Public ________________________________________County of _____________________________, Commonwealth of Kentucky. (Canadian applicants are exempt from this notary requirement) American LegalNet, Inc. www.FormsWorkflow.com Page – 3 Schedule – T 01/01/07 Site ID # SCHEDULE “T” TYPES OF LICENSES & FEES Check ⃞ the box(s) for the type(s) of license(s) you are applying for. To determine the ABC State License(s) fee, find the license type(s) in the left column, and then move right across the table. Licenses issued 6 months or more pay a full year fee. Licenses issued less than 6 months pay one-half year fee. Attach a certified check, cashier check, or a money order. Make check payable to: Kentucky State Treasurer WE DO NOT ACCEPT CASH! AIR TRANSPORTER (liquor / wine / beer) (airlines, charter flight, or commercial cargo systems) PREFIX b Jan. – June July – Dec. Pay this amount LICENSE TYPE Pay this amount AT ⃞ 500.00 250.00 FF ⃞ 100.00 50.00 MT ⃞ 100.00 50.00 NRL ⃞ 100.00 50.00 SMT ⃞ 100.00 50.00 TS ⃞ 100.00 50.00 TT ⃞ 100.00 50.00 (Under Kentucky Law = KRS 243.050(2) (3) FREIGHT FORWARDER (liquor / wine) (Under Kentucky Law = 804 KAR 4:180) MALT BEVERAGE TRANSPORTER (common carriers for hire) (Under Kentucky Law = KRS 243.210) NON-RESIDENT TRANSPORTER (liquor / wine) ((out-of-state distillers, rectifiers, vintners, or wholesalers) (Under Kentucky Law = 804 KAR 4:030) (Vehicles must be marked with Ky. License Type & License Number) SPECIAL BEER TRANSPORTER (distributors, wholesalers, or licensed transporters) (Under Kentucky Law = 804 KAR 4:160) (Vehicles must be marked with Ky. License Type & License Number) TRANSPORTER LIQUOR (liquor / wine) (common carriers for hire) (Under Kentucky Law = KRS 243.200) THROUGH TRANSPORTER (liquor / wine) (vintners, distillers, or licensed common carriers) (Under Kentucky Law = 804 KAR 4:170) TOTALS American LegalNet, Inc. www.FormsWorkflow.com Page 4-Schedule-T 01/01/07 SCHEDULE “T” PAGE (4) Site ID # CHECK LIST 1. Have you answered each question fully and checked the type of licenses you are applying for? ⃞ Yes ⃞ No 2. We do not accept cash! Have you attached a certified check, cashier’s check or money order, Payable to: Kentucky State Treasurer for the license fee? ⃞ Yes ⃞ No 3. Have you signed and had your application notarized? ⃞ Yes ⃞ No 4. Have you attached proof that you have properly qualified to operate in Kentucky? ⃞ Yes ⃞ No (You must attach a copy of your certificate of authority to transport as a common carrier issued by the Department of Transportation Federal Motor Carrier Safety Administration and authorization to operate in Kentucky issued by the Interstate Commerce Commission. Kentucky Department of Transportation, Division of Motor carriers will assist you with this requirement by calling (502) 564-4540. You may now forward this application schedule, 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 http://abc.ky.gov REMINDERS KRS 243.200 Business authorized by distilled spirits and wine transporter’s license. (To transport distilled spirits and wine to or from licensed premises if both the consignor and consignee in each case are authorized by the law of the states of their resident to sell, purchase, ship or receive.). (You must have proper certificates from the Commonwealth of Kentucky Department of Vehicle Regulation to engage in the business of a common carrier.). (For TS applicants). KRS 243.210 Business authorized by a malt beverage transporter’s license. (To transport malt beverages to or from licensed premises if both the consignor and consignee in each case are authorized by the law of the states of their resident to sell, purchase, ship or receive.). (You must have proper certificates from the Commonwealth of Kentucky Department of Vehicle Regulation to engage in the business of a common carrier.) (For MT applicants). KRS 244.150 Licensee to keep records – Common carriers to furnish information. (You must maintain and make readily available upon request adequate books and records of all transactions of shipments of alcoholic beverages to, from, or between persons in Kentucky.) (For all applicants). 804 KAR 8:010 Common Carrier (distilled spirits and wine.) (Common carriers can only transport distilled spirits and wine over the same routes as those authorized to the carrier by the Transportation Cabinet.). (For TS applicants). 804 KAR 8:020 Transporters’ license (distilled spirits and wine.) (For TS applicants). 804 KAR 8:050 Signs on vehicles used by distilled spirits, wine and malt beverage transporters. (Uniform letters in contrasting colors on the right and left side of the vehicle paint the name of the licensee, the Kentucky ABC license type, and the Kentucky ABC license numbers.) (For all NRL and SMT applicants required under 804 KAR 4:030 and 4:160). You may contact our office (502) 564-4850 to obtain full copies of these laws and regulations or obtain copies from Kentucky’s Legislation Research Commission Web Site. http://www.lrc.ky.us American LegalNet, Inc. www.FormsWorkflow.com