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 BRANCH LICENSE Wholesaler of: Intoxicating Liquor $3,000 Malt Beverages $25 LICENSE EXPIRATION DATE: ____________ LICENSE # ________________________ DATE APPROVED ____________ FEDERAL TAX ID # I, _________________________________________ as ____________________________________________ (Owner, Partner or Officer) for and in behalf of __________________________________________________________________________ (Trade Name) __________________________________________________________________________________________ (Home Office Address) (City) (Zip Code) Phone No. (_____)_______________ , Fax No. (_____)_________________ hereby apply for a wholesale branch license to sell alcoholic beverages containing more than 3.2% of alcohol by weight, as herein designated, at: __________________________________________________________________________________________ (Street Address) (City) (Zip Code) The branch establishment shall be under the management of _________________________________________ _________________________________________________________________________________________. _______________________________________________ (Name of Firm) _______________________________________________ (Signature of Affiant) MAKE CHECK PAYABLE TO: DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT AMOUNT RECEIVED PS 09055 (5/06) American LegalNet, Inc. www.FormsWorkflow.com