Minnesota Department of Public Safety ALCOHOL AND GAMBLING ENFORCEMENT DIVISION 444 Cedar Street, Suite 222, St. Paul, MN 55101 (651) 201-7500 TDD (651) 282-6555 FAX (651) 297-5259 TO REPRESENT A DISTILLERY, WINERY OR IMPORTER LICENSE FEE: $600 License Expiration Date: Workers Comp. Ins, Co. Policy Period APPLICANT'S NAME (Business, Partnership, LLC, Corporation) DBA OR TRADE NAME BUSINESS STREET ADDRESS CITY STATE License Number: Date Approved: Policy Number Federal Tax ID Number SOCIAL SECURITY NUMBER APPLICATION DATE BUSINESS PHONE FAX NUMBER ZIP CODE APPLICATION FOR BROKERS LICENSE 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 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 Yes No establishment? If yes, describe (Please attach additional sheet if needed.) TYPE Has the applicant, partners or officers, ever been convicted of any violation of the Minnesota Liquor Control Act or a felony in this state, Yes No any other state, or under federal liquor laws? If yes, give full details. (Please attach additional sheet if needed.) Print Full Name of Applicant and Title Signature of Applicant DOB Date American LegalNet, Inc. www.FormsWorkFlow.com