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 Beer, Malt Beverage, and other Alcoholic Beverages Of Low Content Manufacturer’s Permit 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%) of the permit fee with an additional five percent (5%) for each additional 30 days or fraction thereof. Fee: $1,000.00 For Office Use Only Permit Number Sequence Number Trade Name (if any): Permit to be issued to: Business Location: Street City State Zip Mailing Address: Street City State Zip Business Phone Number: 1. Ownership: Individual Partnership Limited Partnership (requires written agreement) LLC (requires certificate) Corporation (requires certificate) 2. If applicant is other than individual ownership, State of Domicile: 3. Is the permit application for: Same Business New Business 4. Does the applicant’s operations meet the definition of “manufacturer” as provide in La. R.S. 26:241 paragraph 9? YES NO 5. Has applicant file with local authorities for manufacturer’s permit? YES NO 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 % Owned *Partner, Member, Stockholder, or Financial Backer Please complete remainder of form on reverse. American LegalNet, Inc. www.FormsWorkflow.com 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 manufactured. Brand Name Type of Beverage 9. A. An alcoholic beverage tax surety bond in accordance with the provisions of La. R.S. 26:348 and 350 must be furnished in the same name and address as the permit. B. Applicant must comply with the provisions of La. R.S. 26:148 (Cash or Short Term Credit Law). C. This application must be signed by the owner if individual ownership, authorized partner if a partnership, or an authorized agent if a corporation or a limited liability company. D. The person signing this application must fill out and submit 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 liquor permit other than the type applied for in this application. Signature: ______________________________________________________________ Title: Social Security Number: 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