Agent, Broker or Solicitor Renewal Procedures (M.G.L. Ch. 138 S. 18A) Enclosed is an Agent, Broker or Solicitor application to renew your license for the 2008 calendar year. If applicable, also enclosed are applications for renewal of your salesman and transportation permits. All applications must be signed by an officer of the Corporation and submitted with the required fee by November 30th of the calendar year. OUR WEBSITE ADDRESS: www.mass.gov/abcc Payment and Mailing Procedures All applicants must complete the enclosed monetary transmittal form, attach payment and application (s) to the form and mail to: ALCOHOLIC BEVERAGES CONTROL COMMISSION POST OFFICE BOX 3396 BOSTON, MA 02241-3396 Salesman/Transportation applications At the top right of each salesman’s application are the letters SP - . Please put the Salesman’s permit number as given on their 2007 permit here. The Salesman must complete and sign the front of the application. The back of the application, under certificate of employment, is to be completed and signed by an officer of the corporation. Proof of Massachusetts residency is not required when renewing a salesman’s permit, as it should already be on file with this Commission. It is only required for new salesmen. Transportation Applications (please print or type the vehicle identification numbers clearly) At the top right of each transportation application are the letters TD -. Please put the transportation permit number as given on their 2007 transportation permit here. If a vehicle is leased or rented, a copy of the leasing/rental agreement must accompany the application unless a copy is already on file with this Commission. LICENSE FEES: payable to the Commonwealth of Massachusetts AGENT, BROKER OR SOLICITOR LICENSE: $5,000.00 - $500.00 for each additional principal not to exceed $6,500.00 SALESMAN PERMIT FEE: $200.00 TRANSPORTATION PERMIT FEE: $150.00 NOTE: A separate agent’s, broker’s or solicitor’s application must be completed and submitted for approval for each principal you wish to represent in Massachusetts, with the appropriate fee. If you represent more than one principal, please attach to your application a listing of the principals you represent this list should accompany each application filed. American LegalNet, Inc. www.FormsWorkFlow.com The Commonwealth of Massachusetts Department of the State Treasurer Alcoholic Beverages Control Commission 239 Causeway Street Boston, MA 02114 Renewal Application for a License to act as Agent, Broker or Solicitor under provisions of Section 18A, of Chapter 138 of the General Laws, as amended. 2010 Dated at ………………………………. The undersigned hereby applies for a license to act as Agent, Broker or Solicitor for ………………………………………………………………………………………………………………… (Name of principal for whom applicant is to act) ………………………………………………………………………………………………………………… (Address of principal’s place of business) ……………………………………………………………………………………………………….………... (Type of license held by principal. State full and correct name of licensing authority.) It is understood by the applicant that the license being applied for authorizes the solicitation of orders for alcoholic beverages from holders of Wholesalers' and Importers' licenses only for such alcoholic beverages as such holders under their respective licenses are authorized to sell. THE ABOVE STATEMENTS ARE MADE UNDER THE PENALTIES OF PERJURY ………………………………………………………….. (Print name of applicant) ……………………………………………………….….. (Signature of applicant or authorized agent) …..…………………………………………………….. (Address) ………………………………………………………… (Telephone Number) If the application is made by an individual or a partnership, satisfactory proof of citizenship and of residence in this Commonwealth shall be furnished for each individual. If the application is made on behalf of a corporation, satisfactory evidence that a citizen of the United States with full power and authority over all business relative to alcoholic beverages has been appointed to act as manager or principal representative for this purpose shall be furnished. If the application is made on behalf of a foreign corporation, satisfactory evidence that it has been admitted to do business in Massachusetts shall also be furnished. License Fee: $5,000.00 Enclosed find: Check: Money Order: American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF APPOINTMENT TO ACT AS AGENT, BROKER OR SOLICITOR (Not to be filled out if the application on the reverse side is made on behalf of a foreign corporation to act as Agent, Broker or Solicitor on its own account.) The undersigned, being the holder of ……………………………………………………………………………………………… (State type of license held) License No. ………………………… issued by …………………………………………………………………………………….. (State full and correct title of licensing authority) for the sale of ……………………………………………………………………………………………. (State kind of alcoholic beverages) hereby certifies that ……………………………………………………………………………………………... (Name of individual, individuals or corporation appointed) has been appointed to act as Agent. Broker or Solicitor for the purpose of soliciting orders for alcoholic beverages from the holders of Wholesalers' and Importers' licenses in the Commonwealth of Massachusetts for our account. THE ABOVE STATEMENTS ARE MADE UNDER THE PENALTIES OF PERJURY ……………………………………………………………………………………… (Typewrite or print – Do not write – full and correct name) ……………………………………………………………………………………… (Signature) ……………………………………………………………………………………… (Mail Address) ……………………………………………………………………………………… Pursuant to M.G.L. Ch. 62C, Sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. ______________________________ Social Security Number Or Corporate Name ___________________________________ Signature of Individual Date ____________________________by:_______________________________ Federal Identification Number (if applicable) Corporate Officer Date American LegalNet, Inc. www.FormsWorkFlow.com The Commonwealth of Massachusetts Department of the State Treasurer Alcoholic Beverages Control Commission 239 Causeway Street Boston, MA 02114 Agent, Broker or Solicitor Applicants I hereby advise that (Print or type name of Principal, (Certificate of Compliance Holder) whom I represent in Massachusetts under an Agent, Broker or Solicitor’s License, No.______ is offering for sale in Massachusetts the following brands and kinds of alcoholic beverages, and the name of the Massachusetts Wholesaler/Importer distributing each item. (Please inform the Commission immediately of any additions.) BRANDS/KINDS WHOLESALER/IMPORTER ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ List all Principals (Certificate of Compliance Holders) you presently represent in Massachusetts. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ THE ABOVE STATEMENTS ARE MADE UNDER PENALTY OF PERJURY. SIGNATURE AND TITLE DATE American LegalNet, Inc. www.FormsWorkFlow.com The Commonwealth of Massachusetts Department of the State Treasurer Alcoholic Beverages Control Commission 239 Causeway Street Boston, MA 02114 FORM A THIS FORM MUST BE COMPLETED FOR EACH: _____ A. NEW LICENSE APPLICANT _____ B. APPOINTMENT OR CHANGE OF MANAGER IN A CORPORATION _____ C. TRANSFER OF LICENSE (RETAIL ONLY-SEC. 12 & SEC. 15) (Please check which transaction is the subject of an application accompanying this Form A.) PLEASE TYPE OR PRINT ALL INFORMATION ALL QUESTIONS MUST BE ANSWERED AND TELEPHONE NUMBERS PROVIDED OR APPLICATION WILL NOT BE ACCEPTED. 1. LICENSEE NAME_______________________________________________________________ (NAME AS IT WILL APPEAR ON THE LICENSE) 2. NAME OF (PROPOSED) MANAGER _______________________________________________ 3. SOCIAL SECURITY NUMBER ____________________________________________________ 4. HOME (STREET) ADDRESS ______________________________________________________ 5. AREA CODE AND TELEPHONE NUMBER (S): (Give both, your home telephone and a number at which you can be reached during the day). DAY TIME # ____________________________HOME #____________________________ 6. PLACE OF BIRTH: ________________________ 8. REGISTERED VOTER: _______ YES _______ NO 8A. WHERE ?: ______________________ 9. ARE YOU A U. S. CITIZEN: 10. COURT AND DATE OF NATURALIZATION (IF APPLICABLE): _______________________ (Submit proof of citizenship and/or naturalization such as Voter’s Certificate, Birth Certificate or Naturalization Papers) 11. FATHER’S NAME: ________________12. MOTHER’S MAIDEN NAME: ________________ 13. IDENTIFY YOUR CRIMINAL RECORD, (Massachusetts, Military, any other State or Federal): any other arrest or appearance in criminal court charged with a criminal offense regardless of final disposition: __________ YES __________ NO (must check either yes or no) _______ YES 7. DATE OF BIRTH: __________________ _______ NO IF YES, PLEASE DESCRIBE OFFENSE (S) SPECIFIC CHARGE AND DISPOSITION (FINE, PENALTY, ETC.) American LegalNet, Inc. www.FormsWorkFlow.com _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 14. PRIOR EXPERIENCE IN THE LIQUOR INDUSTRY: IF YES, PLEASE DESCRIBE: ________ YES ________ NO _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 15. FINANCIAL INTEREST, DIRECT OR INDIRECT, IN THIS OR ANY OTHER LIQUOR LICENSE, PERMIT OR CERTIFICATE: ____________ YES ____________ NO If YES, please describe:___________________________________________________________ 16. _______________________________________________________________________________ EMPLOYMENT FOR THE LAST TEN YEARS (Dates, Position, Employer, Address and if known, Telephone Numbers): _______________________________________________________________________________ _______________________________________________________________________________ 17. HOURS PER WEEK TO BE SPENT ON THE LICENSED PREMISES: ____________________ 18. I hereby swear that under the pains and penalties of perjury that the information I have given in this application is true to the best of my knowledge and belief. BY:________________________________________________________ PROPOSED MANAGER SIGNATURE American LegalNet, Inc. www.FormsWorkFlow.com MONETARY TRANSMITTAL FORM 1 THIS TRANSMITTAL MUST ACCOMPANY YOUR APPLICATION IN ORDER TO ASSURE PROPER CREDIT. PLEASE DO NOT SEND CASH. PLEASE MAKE YOUR CHECKS PAYABLE TO COMMONWEALTH OF MASSACHUSETTS, ABCC. MAIL THIS TRANSMITTAL ALONG WITH YOUR CHECK AND COMPLETED APPLICATION TO: BANK OF AMERICA - ALCOHOLIC BEVERAGES CONTROL COMMISSION POST OFFICE BOX 3396 BOSTON, MA 02241-3396 APPLICANT MUST COMPLETE THE FOLLOWING: NAME: ADDRESS: CITY/TOWN: DATE: LICENSE NAME AIRLINE MASTER FOR SALE TO PASSENGERS AIRLINE (EACH FLIGHT) BROKERS BROKERS (ADDITIONAL) BONDED WAREHOUSE SALESMAN TRANSP. FOR SALESMAN RAILROAD MASTER FOR SALE TO PASSENGERS RAILROAD (EACH RR CAR) STEAMSHIP SHIP CHANDLER TRANSPORTATION & DELIVERY WAREHOUSEMAN PERMIT TO TRANSPORT NOT FOR CONSUMPTION RR, SHIP, OR AIRLINE STATE: ZIP CODE: REV. CODE # OF PERMITS REQUESTED FEE AMOUNT TOTAL 3094 3094 3007 3007 3095 3011 3097 ________ ________ ________ ________ ________ ________ ________ $ 500.00 $ 50.00 $ 5000.00 $ 500.00 $ 1000.00 $ 200.00 $ 150.00 $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ 3009 3009 3010 3099 3097 3095 ________ ________ ________ ________ ________ ________ $ 500.00 $ 50.00 $ 500.00 $ 1000.00 $ 150.00 $ 500.00 $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ 3097 ________ $ 1500.00 $ ________ CHECK TOTAL $_________ 3/04 REV American LegalNet, Inc. www.FormsWorkFlow.com