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 Wine Producer’s Permit To: Commissioner, Office of Alcohol and Tobacco Control Permit to be issued for one year ending on December 31, Permit to be issued to: (name of individual, partnership, limited partnership, or corporation) Trade Name: Physical Location of Winery: (this description should be sufficient to allow a person to locate the facility) Mailing Address: City or town: Parish: Ward: (if different than physical location) 1. Ownership: Individual Partnership (requires written agreement) Limited Partnership Corporation (requires certificate) (requires certificate) 2. If corporation, show state of domicile: If domicile is not in Louisiana, is corporation authorized to do business in Louisiana? YES NO 3. If partnership, is partnership recognized by Louisiana law? YES NO 4. Is the application for a: Renewal permit for same business and location Permit for new business or new location 5. Does applicant meet the definition of “wine producer” as provided in R.S. 26:2(21)? YES NO 6. Does applicant meet the definition of “winery” as provided in R.S. 26:2(22)? YES NO American LegalNet, Inc. www.FormsWorkflow.com 8. If a partnership or corporation, list below names, addresses, and percentage of business owned by each partner or stockholder. Schedule “A” must be attached for each partner, or for each stockholder owning more than 5% of the stock. Also, any financial backers of the business must be listed and Schedule “A” submitted. Name of Person Address *Kind of Interest % Owned * Partner, stockholder, or financial backer 9. (a) Is applicant’s business to be conducted wholly or partly by one or more managers, agents or other representatives? YES NO (b) If yes, such persons shall also possess the same qualifications of the applicant and form Schedule “A” must be submitted on each. (c) As to stockholders, managers, agents, representatives or other associated individuals, form Schedule “A” must be furnished for additional personnel as those changes occur. 10. List below the brand name of each wine and the type of each wine you intend to produce or sell, whether at wholesale or retail. Any additions or deletions from this list shall be reported promptly to this office with the appropriate affidavit. (If additional space is needed, please use a separate sheet of paper and write the number “10” on it. Attach the paper to this application.) REQUIRED: 11. (a)An Alcoholic Beverage Tax Surety Bond in accordance with the provisions of LRSA 26:348 must be furnished in the same name and address as the permit. (b) Applicant must comply with provisions of LRSA 26:148 (Cash or Short Term Credit Law). See instructions. AFFIDAVIT 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. 26:80 and 280.. 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