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 BROKER'S LICENSE TO REPRESENT A DISTILLERY, WINERY OR IMPORTER (FEE: $600) LICENSE EXPIRATION DATE:____________ LICENSE #: ________________________DATE APPROVED: _____________ Workers Comp. Ins. Co._________________________Policy # ____________________________Policy Period_______________________ FEDERAL TAX ID # APPLICANT'S NAME (Business, Partnership, LLC, Corporation) DOB SOCIAL SECURITY # APPLICATION DATE DBA OR TRADE NAME BUSINESS PHONE ( ) FAX NUMBER ( ) STATE ZIP CODE BUSINESS STREET ADDRESS CITY NAME, ADDRESS AND TYPE OF BUSINESS (DISTILLERY, WINERY, IMPORTER) TO BE REPRESENTED. FOR EACH FIRM LISTED, THE APPLICANT MUST ATTACH A STATEMENT OF REPRESENTATION. NAME TYPE ADDRESS, CITY, STATE, ZIP CODE NAME TYPE ADDRESS, CITY, STATE, ZIP CODE Does the applicant or associates hold any retail alcohol beverage license, or have any financial or other interest in such a license or establishment? No Yes If yes, describe (Please attach additional sheet if needed.) Has the applicant, partners or officers, ever been convicted of any violation of the Minnesota Liquor Control Act or a felony in this state, any other state, or under federal liquor laws? No Yes If yes, give full details.(Please attach additional sheet if needed.) Print Full Name of Applicant and Title Signature of Applicant DOB Date NOTE ID cards must be obtained for each employee of the broker at a fee of $20 each. PLEASE MAKE CHECKS PAYABLE TO: DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT PS 09080 (5/06) AMOUNT RECEIVED_______________________________ American LegalNet, Inc. www.FormsWorkflow.com