12072006 LOUISIANA DEPARTMENT OF REVENUE OFFICE OF ALCOHOL AND TOBACCO CONTROL P.O. BOX 66404 BATON ROUGE, LOUISIANA 70896-6404 TELEPHONE (225) 925-4041 – FAX (225) 925-3975 Application for Microbrewer Permit OFFICE USE ONLY Microbrewer Permit Number: Telephone Number INSTRUCTIONS: Application must be complete with proper fees in the form of a money order, cashier’s check, or certified check, made payable to the Office of Alcohol and Tobacco Control. Application must be typed or printed in ink and must be signed and sworn to before a Notary Public. APPLICANTS FULL NAME: (must be same as shown on Class A Beer Permit) TRADE NAME: (must be same as shown on Class A Beer Permit) LOCATION ADDRESS: Street/City/State/Zip MAILING ADDRESS: P.O. Box/street/city/state/ZIP 1. Do you hold a Class A Retail Beer license with the State of Louisiana, Office of Alcohol and NO Tobacco Control at this location? YES If yes, give permit number. 2. (a) Do you have equipment to brew beer or other malt beverages on this premise? YES NO (b) What is the capacity of your microbrewing equipment? (c) How much do you anticipate brewing for the licensed year? 3. Do you plan to sell the beverage you brew off the licensed premise? YES NO If so, how will the beverage be packaged for sale? 4. Have you complied with all the applicable health department requirements on your brewing equipment? YES NO American LegalNet, Inc. www.FormsWorkflow.com WARNING: THE MICROBREWER PERMIT WILL NOT ALLOW YOU TO SELL THE MANUFACTURED BEVERAGE AT WHOLESALE MICROBREWER PERMIT TO BE ISSUED FOR THE SAME PERIOD AS YOUR CLASS A BEER PERMIT. FEE: $1,000.00 Circle and initial parish and corresponding expiration date. January expiration May expiration September expiration Ascension Orleans Bienville East Baton Rouge Bossier June expiration None Caddo February expiration Jefferson Claiborne July expiration Avoyelles DeSoto March expiration Allen Evangeline Lincoln Beauregard Iberville Red River Calcasieu Pointe Coupee Sabine Cameron Rapides Webster Jefferson Davis St. Landry October expiration Vermillion West Baton Rouge Acadia Vernon Iberia August expiration East Feliciana Lafayette April expiration Plaquemines Livingston St. Martin St. Bernard St. Helena November expiration St. Charles St. Tammany Assumption St. James Tangipahoa Lafourche St. John Washington St. Mary West Feliciana Terrebonne December expiration Caldwell Catahoula Concordia East Carroll Franklin Grant Jackson LaSalle Madison Morehouse Natchitoches Ouachita Richland Tensas Union West Carroll Winn Note: Your permit will expire at the same time as your Class A Beer Permit. You must renew one (1) month prior to expiration to avoid penalties. AFFIDAVIT This affidavit must be signed by the same person authorized to sign the Class A Beer application and must be notarized by a notary public. I swear that I have read each of the questions in this application and that the answers which I have given are true and correct to the best of my knowledge and that I meet the qualifications and conditions set out in LA. R.S. 26:241, 271, 271.1, and 273. 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: American LegalNet, Inc. www.FormsWorkflow.com