Commonwealth of Massachusetts Alcoholic Beverages Control Commission 239 Causeway Street Boston, MA 02114 www.mass.gov/abcc The Application for a Licensee's Permit to Transport and Deliver Alcoholic Beverages MONETARY TRANSMITTAL FORM [APPLICATION MUST BE COMPLETED ONLINE] ONE CHECK PER TRANSMITTAL SHEET ECRT CODE: TRAN CHECK PAYABLE TO ABCC OR COMMONWEALTH OF MA: $150.00 (CHECK MUST DENOTE THE NAME OF THE LICENSEE CORPORATION, LLC, PARTNERSHIP, OR INDIVIDUAL) CHECK NUMBER IF USED EPAY, CONFIRMATION NUMBER: A.B.C.C. LICENSE NUMBER (IF AN EXISTING LICENSEE): LICENSEE NAME: ADDRESS: CITY/TOWN: STATE LICENSE TYPE FEE TRANSPORTATION PERMIT $150.00 ZIP CODE # OF PERMITS 1 COST $150.00 YOU MUST MAIL THIS TRANSMITTAL FORM ALONG WITH YOUR CHECK AND COMPLETED APPLICATION TO: ALCOHOLIC BEVERAGES CONTROL COMMISSION P. O. BOX 3396 BOSTON, MA 02241-3396 American LegalNet, Inc. www.FormsWorkFlow.com YEAR 20 Application for a Licensee's Permit to Transport and Deliver Alcoholic Beverages (M.G.L. Chapter 138, §22) TD 1. Applicant Information: Applicant Name: Business Name (d/b/a, if different) Address of Premises: City/Town: Telephone: State Zip E-mail Address ABCC License Number: 2 Applicant is a: §12 Restaurant §12 Hotel §12 Club §12 Tavern §12 Veterans Club §12 General of Premises * Transportation Permit for a §12 Licensee allows pickup of alcoholic beverages only from lawful suppliers - NO DELIVERIES §15 Package Store §18 Wholesaler/Importer §19A Salesman §19E Farmer-Distilleries §19 Manufacturer §19B Farmer-Winery §19C Farmer-Brewery *Transportation Permit for a §15, §18, §19, §19B, §19C & §19E is for pickup from lawful suppliers and deliveries to lawful buyers. 3 Applicant is Licensed to Sell: All Alcoholic Beverages Wine & Malt Beverages Wines or Malt Beverages 4. Vehicle Information: Address where the vehicle is principally garaged: Vehicle Identification # Vehicle Registration #: Vehicle Make:: Vehicle Model: If the vehicle is owned or leased by an employee, provide the name and address of the registrant: Employee Name Employee Address Employment Capacity *If additional space is needed, use the last page* I understand that each representation in this application is material to the determination of the application and state under penalty of perjury that all statements and representations therein are true. Signature Title Date American LegalNet, Inc. www.FormsWorkFlow.com Additional Space American LegalNet, Inc. www.FormsWorkFlow.com