Minnesota Department of Public Safety ALCOHOL AND GAMBLING ENFORCEMENT DIVISION 445 Minnesota Street, Suite 222, St. Paul, MN 55101 (651) 201-7507 TDD (651) 282-6555 FAX (651) 297-5259 APPLICATION FOR BRANCH LICENSE Wholesaler of: Intoxicating Liquor $3,000 Wholesaler of: Malt Beverages $25 Wholesaler of: Wine - No Fee License Expiration Date: I, for and in behalf of License Number: Date Approved: as (Owner, Partner or Officer) (Trade Name) (Home Office Address) (City) (Zip Code) Phone Number , Fax Number hereby apply for a wholesale branch license to sell alcoholic beverages containing more than 3.2 % of alcohol by weight, as herein designated, at: The branch establishment shall be under the management of Name of Firm Signature of Affiant MAKE CHECK PAYABLE TO: ALCOHOL & GAMBLING ENFORCEMENT DIVISION AMOUNT RECEIVED *Office of Enterprise Technology American LegalNet, Inc. www.FormsWorkFlow.com