Louisiana Department of Revenue Office of Alcohol and Tobacco Control P.O. Box 66404 Baton Rouge, LA 70896 (225) 925-4041 Bobby Jindal Governor 082110 Out of State Manufacturer/Supplier’s Permit Application Individual Corporation LLC Business Name P.O. Mailing Address (If Different) Limited Partnership (LP) Business Location Street Primary Contact Person (Last, First, Middle) Business Telephone Number Partnership City Title Business Fax Number Email Address Please answer questions PERMITS EXPIRE DECEMBER 31 of EACH YEAR 1. Is this business a Manufacturer/Supplier of products of LOW ALCOHOL CONTENT (alcoholic beverages containing not more than six percent alcohol by volume)? Yes No 2. Is this business a Manufacturer/Supplier of products of HIGH ALCOHOL CONTENT? (alcoholic beverages containing more than six percent alcohol by volume.)? Yes No 3. Does this business manufacture its own products? Yes No 4. Does this business import foreign (outside U.S.) product(s) and ship to Louisiana Wholesalers? Yes No 5. How many cases of alcoholic beverage did this business sell to wholesalers in Louisiana last calendar year? 6. Does this business hold a Wholesale license or Supplier / Manufacturer license from the state in which the business domiciled? Yes No (If yes, attach a copy of the license to this application) 7. Does this business hold a “TTB” permit? Yes No (If yes, attach a copy of the permit to this application) 8. Does this business have written approval from the Louisiana Department of Revenue to ship alcoholic beverages into Louisiana? Yes No (If yes, attach a copy of the approval to this application) Complete the reverse side of this form and apply attachments to this application regarding this section if necessary. Sign the affidavit, have it notarized and mail with the appropriate fee to: Louisiana Department of Revenue Office of Alcohol and Tobacco Control P.O. Box 66404, Baton Rouge, LA 70896-6404 American LegalNet, Inc. www.FormsWorkFlow.com List name and address of Wholesaler(s) that will receive your products Name: Address: List all Brands Supplied by this Business Brands FEES Manufacturers/Suppliers who sell less than one thousand cases of their product in the state - $200.00 All other out of state manufacturers and suppliers - $1000.00 Enter amount enclosed for this application: $ Make money order, company check, or certified check payable to: Louisiana Dept. of Revenue/LA ATC Signature/Notary Your company will not be able to sell / distribute products containing alcohol of high or low content to any Louisiana wholesale dealer or distributor, regardless of whether the sale is consummated inside or outside the State of Louisiana, until the fee has been paid. I swear that the information that I have given is true and correct to the best of my knowledge and that I have read and understand every section on this application. Signature: Title: Print/Type your name: Sworn to and subscribed to me this in the county of Notary Public’s Signature: day of , 20 , State of Print Name of Notary Public: American LegalNet, Inc. www.FormsWorkFlow.com