120606 FOR OFFICE USE ONLY Permit Number: State of Louisiana Office of Alcohol and Tobacco Control 8549 United Plaza Blvd, Suite 220 P.O. Box 66404 Baton Rouge, LA 70896-6404 Telephone (225) 925-4041 · Fax (225) 925-3975 Sequence Number: Application for Wholesale Malt Beverage Permit Page 1 of 2 1. Type of Permit: * Malt Beverages NOT containing more than six percent alcohol by volume as defined in L.R.S. 26:241(18)(a) *“Wholesale dealer” of malt beverages containing not more than six percent alcohol by volume” means those persons who sell malt beverage containing not more than six percent alcohol by volume and alcoholic beverages of low alcoholic content to licensed wholesale dealers or licensed retail dealers exclusively, within the state or to any person for delivery beyond the borders of the state to a licensed dealer in that state and who conduct a bona fide wholesale business and maintain a warehouse or warehouses for the storage and warehousing of malt beverages and alcoholic beverages of low alcoholic content in the area where domiciled and licensed by the state, and conduct and maintain systematic and regular solicitations, distributions, delivery, and sales of said beverages to licensed retail dealers located within the boundaries of each parish, municipality, or geographic area, as contractually defined between the wholesaler and his supplier, in which the wholesale dealer makes any sales or delivery. ** Malt Beverages containing MORE than six percent alcohol by volume as defined in L.R.S. 26:241(18)(b) **“Wholesale dealer of malt beverages containing more than six percent alcohol by volume” means those persons who sell malt beverages containing more than six percent alcohol by volume and alcoholic beverages of low alcoholic content to licensed wholesale dealers or licensed retail dealers exclusively, within the state or to any person for delivery beyond the borders of the state to a licensed dealer in that state and who conduct a bona fide wholesale business and maintain a warehouse or warehouses for the storage and warehousing of malt beverages and alcoholic beverages of low alcoholic content in the area where domiciled and licensed by the state, and conduct and maintain systematic and regular solicitations, distributions, delivery, and sales of said beverages to licensed retail dealers located within the boundaries of each parish, municipality, or geographic area, as contractually defined between the wholesaler and his supplier, in which the wholesale dealer makes any sales or delivery. 2. Type of Ownership: Individual Corporation (Requires certificate and corporate documents) Partnership (Requires written agreement) 3. Applicant’s Name (individual, partnership, corporation, LLC): LLC (Requires certificate and organizational documents) 4. Trade Name of Business (if applicable): 5. Primary Contact Person (Last, First, Middle) & Title: 6. Business Phone #: 7. Business FAX #: ( ( ) - 8. Location Address (street/city/state/zip): ) - 9. Location Parish/County 10. Mailing Address (street/city/state/zip): 11. Does this business maintain an active email address? Yes 12. Does this applicant maintain an active Business Web Site? No If yes, apply the email address below. Yes No If yes, enter the Internet Address below. 13. Does this applicant allow individual consumers to purchase alcoholic beverage products directly from the business Web Site listed in question number Yes No N/A twelve (12) of this application? 13a. Does this applicant allow individual consumers to purchase alcoholic beverage products directly from the business by any means? If yes, please explain below or in an attachment. Yes 14. Does this applicant’s operation meet the definition of “wholesale dealer” as set forth in L.R.S. 26:241(18)(a) and L.R.S. 26:241(18)(b)? If no, please explain below or in an attachment. Yes No No 15. Has this applicant read L.R.S. 26:359 with reference to the importation and warehousing of malt beverages? Yes No Note: Each applicant wishing to obtain a “wholesale dealer” permit is encouraged to become familiar with L.R.S. 26:359. 16. If applicant is a partnership, corporation, or LLC, list the name, address, title, and percentage of ownership of each partner or stockholder. Please provide an attachment relative to this section if necessary. Note: A Schedule “A” must be completed and attached for the manger, owner, each partner, officer, director, financial backer, and any stockholder owning more than 5 percent of the stock, if applicable. Name: Title: % of Stock American LegalNet, Inc. www.FormsWorkflow.com Page 2 of 2 17. Is applicant a new ownership to succeed an established on-going business? Yes No If yes, name of previous owner: 17a. Trade Name of Business: 17b. Permit Number: 17c. Class and Type: 18. Does this applicant have knowledge of two (2) separate beer taxes (STATE AND LOCAL), tax reports, and payment of taxes? If no, please explain below or in an attachment. 19. Has applicant applied to local authorities for a “wholesale dealer” permit? If no, please explain below or in an attachment. Yes Yes No No 20. Does this applicant know of the beer cash laws and regulations? Yes No If no, please explain below or in an attachment. Note: Each applicant wishing to obtain a “wholesale dealer” permit is encouraged to become familiar with beer cash laws and regulations (Title 55:VII). 21. Does this applicant maintain warehouse space? Owned by applicant Yes No If yes, select below how warehouse space is maintained. Leased by applicant Dedicated exclusively for this applicant’s use in a public warehouse 22. Is the warehouse space maintained by this applicant sufficient to store, at one time, a stock of alcohol equal to at least 10% of its annual case Yes No volume of alcohol sales at wholesale to retailers? 23. Does this applicant maintain, at all times, a stock of alcohol in its warehouse which is owned by the applicant, not consigned, and which cost $50,000 Yes No or more to acquire? 24. Does this applicant maintain delivery equipment? Owned by applicant Yes No If yes, select below how equipment is maintained. Leased by applicant 25. Will this applicant maintain brand representation? Yes Dedicated exclusively for this applicant’s use in a public warehouse No If yes, provide the details requested in questions 26 & 27 of this application. 26. List, *by attachment, each brand of malt beverage this business intends to sell NOT containing more than six percent alcohol by volume, the manufacturer, and the manufacturer’s city and state. *Apply attachment to this application regarding this requested information. 27. List, *by attachment, each brand of malt beverage this business intends to sell that contains MORE than six percent alcohol by volume, the manufacturer, and the manufacturer’s city and state. *Apply attachment to this application regarding this requested information. 28. *State the parishes in which this applicant maintains sales of alcohol to retailers at wholesale and give the number of retailers that it sells alcoholic Beverages to in each of those parishes in the space provided below. Parish Number of Retailers *Apply attachment to this application if necessary. 29. Will this applicant’s sales to retailers account for at least 50% of the gallonage it handles, excluding sales made by the applicant to retailers in which it Yes No holds interest. Wholesale Malt Beverage Permit Fee: $1000.00 This affidavit must be signed by the owner, if individual ownership; authorized partner, if partnership; or authorized officer and/or official, if corporation or LLC. Misstatement or suppression of material facts in this application is grounds for denial of this permit. Conviction of filing false public records, a violation of Louisiana Revised Statute 14:133, may result in imprisonment for not more than five years with or without hard labor and fines of not more than $5000.00 (five thousand dollars), or both. Affidavit I hereby apply for a Wholesale Malt Beverage Permit as required by Title 26 of Louisiana Revised Statutes. Under the penalties of perjury, I declare that I have examined this application, including all accompanying documents, and to the best of my knowledge and belief, it is true, correct, and complete. Signature: Title: Print/Type your name: Sworn to and subscribed to me this in the parish/county of Notary Public’s Signature: day of , 20 State of Print Name of Notary Public: American LegalNet, Inc. www.FormsWorkflow.com