12072006 OFFICE OF ALCOHOL AND TOBACCO CONTROL LOUISIANA DEPARTMENT OF REVENUE P.O. BOX 66404 BATON ROUGE, LOUISIANA 70896-6404 TELEPHONE (225) 925-4041 – FAX (225) 925-3975 Application for High Alcohol Content Manufacturer’s/Supplier’s Permit Permit to be issued for the year ending December 31, 20 Permit to be issued to: Trade Name (if any): Mailing Address: Location Address: Location Parish: 1. Ownership: Phone Number: Individual Partnership Corporation LLC 2. If other than Individual ownership, show State of Domicile: 3. Is the application for permit for same business or for a new business? Same Business 4. Has applicant filed with local authorities for a high alcohol content manufacturer’s permit? New Business YES NO 5. Does this applicant’s operation meet the definition of a “manufacturer” as provided in R.S. 26:2(10)? 6. If a partnership or corporation, list below names, addresses, and percentage of business owned by each partner or stockholder. A Schedule “A” form must be attached for each partner or each stockholder owning more than 5% of the stock. Also, any financial backers of the business must be listed and a Schedule “A” form submitted. Name of Person Address *Kind of Interest YES NO % Owned *Partner, Member, Stockholder, or Financial Backer 7. Is applicant’s business to be conducted wholly or partly by one or more managers, agents, or other representatives? YES NO **If yes, such persons shall also possess the same qualifications of the applicant and a Schedule “A” form must be submitted on each. **As to partners, members, stockholders, managers, agents, representatives, or other associated individuals, a Schedule “A” form must be furnished for such additional personnel as any changes occur. 8. List below alcoholic beverages to be handled and source supply: Brand Name Distillery/Winery City and State Please complete remainder of form on reverse. American LegalNet, Inc. www.FormsWorkFlow.com Required A. An Alcoholic Beverage Tax Surety Bond in accordance with the provisions of La. R.S. 226:348 must be furnished in the same name and address as the permit. B. This application must be signed by the owner if individual ownership, authorized partner if a partnership, or an authorized agent or officer if a corporation or LLC. C. The person (manager, stockholder, partner, broker) signing this application must fill out and sign a Schedule “A” form. Affidavit I swear (or affirm) that I have read each of the questions in this application and that the answers that I have given are true and correct to the best of my knowledge. I also swear (or affirm) that this applicant (except as provided in R.S. 26:85) holds no interest either directly or indirectly in a high alcohol content permit other than the type applied for in this application. Signature: ______________________________________________________________ Title: Print/Type your name: Sworn to and subscribed to me this In the parish of day of , 20 , State of Notary Public’s Signature: ________________________________________________ Print Name of Notary Public: In addition to other penalties, failure to file application before beginning business or for renewal of permit not later than November 1 of each year will incur penalties of five percent (5%) for each additional thirty days or fraction thereafter. Fee $1,000.00 Permit Number For Office Use Only Sequence Number Fee Penalty Total American LegalNet, Inc. www.FormsWorkFlow.com