Minnesota Department of Public Safety ALCOHOL AND GAMBLING ENFORCEMENT DIVISION 444 Cedar Street/Suite 133, St. Paul, MN 55101-5133 (651) 201-7506 TDD (651) 282-6555 FAX (651) 297-5259 APPLICATION FOR A WHOLESALER'S/MANUFACTURER'S INTOXICATING LIQUOR LICENSE LICENSE EXPIRATION DATE _____________ LICENSE # _________________________ DATE APPROVED____________ WORKERS COMP. INS. CO. __________________POLICY # ________________________ POLICY PERIOD________________ MINNESOTA TAX ID # FEDERAL TAX ID # Licensee's name (business, partnership, LLC, corporation) DOB Social Security # DBA or trade name Business address Phone City State Warehouse Fax # Zip Code License period From City Date of incorporation State of incorporation Certificate number To State Is corporation authorized to do business in Minnesota? Yes No Indicate type: Submit a certified check and a surety bond in the amount specified. Wholesaler of Intoxicating liquor Fee - $15,000 Manufacturer Fee - $30,000 Bond - $10,000 Brewer (brews over 3500 barrels annually) Brewer (brews between 2000 -3500 barrels annually) Wholesaler of Wine Fee - $4,000 Fee - $ 500 Fee - $3,750 Bond - $1,000 Wholesaler of Malt Beverages Fee - $1,000 Bond - $1,000 Wine Manufacturer Fee - $500 Bond - $5,000 Micro Brewer (brews under 2000 barrels anually) Fee - $150 Bond - $1,000 Brew Pub Fee - $500 Bond - None Farm Winery Fee - $50 Bond - $5,000 Bond - $5,000 Give full name, address, DOB, Social Security # and title of the applicant and for all partners or officers and principal stockholders for corporations. State below the partnership interest of each partner and for a corporation the percentage of stock held by each officer. Name DOB Address City Name DOB Address City Name DOB Address City PS 09101 (5/06) Social Security # Title Percent stock of partnership interest State Social Security # Title Percent stock of partnership interest State Social Security # Zip Code Title Zip Code Percent stock of partnership interest State Zip Code MAKE CHECK PAYABLE TO: DIRECTOR ALCOHOL AND GAMBLING ENFORCEMNT AMOUNT RECEIVED American LegalNet, Inc. www.FormsWorkflow.com Describe the storage and warehousing facilities and/or the bottling and production capacity and the number of floors used.________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ List basic federal permit and other permit numbers with their effective dates. Permit type _______________________ Permit # __________________________Effective date ___________ Permit type _______________________ Permit # __________________________Effective date ___________ Give the address of all branch establishments owned by the applicants in Minnesota. Street address, city__________________________________________________________________________ Street address, city__________________________________________________________________________ State whether applicant or any person named herein own any stock or have any financial interest in any brewery, manufacturer, wholesaler or retail alcoholic beverage establishment in this State or any other State. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ State whether applicant, partners, or officers were ever indicted or convicted for any violation of the Minnesota Liquor Control Act or a felony in this State or any other State or under federal laws. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Manufacturers and Brewers: Names of Minnesota Wine and Beer Wholesalers.(Attach additional sheet if needed) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Wholesalers of malt beverages: State the name and address of the producers of the beverages to be distributed. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ All statements and documents submitted with this application shall become a permanent part of the record. The Liquor Control Director has the right to reject or revoke any license or license application containing a false statement. I certify that the information submitted is true and correct to the best of my knowledge. Print full name of applicant and title Signature of applicant Date NOTE If this application is for a new partnership, submit a certified copy of the partnership agreement. For a new corporation, include a certified copy of the articles and by-laws. If this application is for a license renewal, submit a copy of any amendment made to the partnership agreement or the articles of incorporation and by-laws since the last license was issued. Identification cards must be obtained for each salesperson employed. Fee is $20 per card and will expire at the same time as this license. American LegalNet, Inc. www.FormsWorkflow.com