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 (You Must Submit a VALID Liquor Liability Insurance Certificate to this Application) License Expiration Date: Workers Comp. Insurance Co: Policy Period: MN State Tax ID Number: DOB Phone Number State Zip Code Identification Number: Policy Number: Federal Tax ID Number: Social Security Number Fax Number License Period To APPLICATION FOR FARM WINERY LICENSE Licensee's Name (Business, Partnership, LLC, Corporation) Business Address City From Date of Incorporation State of Incorporation Certificate Number Is corporation authorized to do business in Minnesota? Yes No Indicate type of license applying for and submit check and/or surety bond in the amount specified. Farm Winery Total License Fee: $50 $5,000 Surety Bond required (Only necessary for new licensees after Jan 1, 2010) $10,000 Surety Bond required (Only necessary for new licensees after Jan 1, 2010) Distilled Spirits Total License Fee: $50 Give full name, address, DOB, Social Security Number and title of the applicant(s) and for all partners or officers and principal stockholders for corporations. State below the partnership interest of each partner. For a coporation, the percentage of stock held by each officer. Name DOB Social Security Number Title Financial Interest % Address Name Address Name Address Name Address DOB DOB DOB City Social Security Number City Social Security Number City Social Security Number City Title State Title State Title State State Zip Code Financial Interest % Zip Code Financial Interest % Zip Code Financial Interest % Zip Code MAKE CHECK PAYABLE TO: ALCOHOL & GAMBLING ENFORCEMENT DIVISION American LegalNet, Inc. www.FormsWorkFlow.com Is the applicant an owner/operator of a farm where the wine/distilled spirits are manufactured under this license? Yes No Total number of gallons of wine manufactured using MINNESOTA grown produce in the preceding 12 months. Total number of gallons of wine manufactured using produce grown OUTSIDE OF MINNESOTA in the preceding 12 months. Total number of gallons of spirits manufactured in the preceding 12 months. List all federal permit and other permit numbers with their effective date AND attach photocopy of each. Permit Type: Permit Type: Permit Type: Permit Type: Effective Date: Effective Date: Effective Date: Effective Date: Permit Number: Permit Number: Permit Number: Permit Number: 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. If yes, give details. All statements and documents submitted with this application shall become a permanent part of the record. Alcohol and Gambling Enforcement Division has the right to reject or revoke any licenses or license application containing a false statement. I certify that all 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 amendments made to the partnership agreement or the articles of incorporation and by-laws since the last license was issued. American LegalNet, Inc. www.FormsWorkFlow.com