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 APPLICATION FOR LICENSE TO SELL INTOXICATING OR 3.2 % MALT LIQUOR ON A COMMON CARRIER INTOXICATING (INCLUDES 3.2% MALT LIQUOR) LIQUOR 3.2% MALT LIQUOR ONLY SUNDAY INTOXICATING LIQUOR License Expiration Date: Workers Comp. Ins, Co. Policy Period CARRIER'S NAME APPLICANT'S NAME AND TITLE MAIN ADDRESS OF CARRIER CITY STATE $250 $50 $75 License Number: DUPLICATE LICENSE DUPLICATE LICENSE DUPLICATE LICENSE Date Approved: Policy Number Federal Tax ID Number LICENSE PERIOD FROM TO BUSINESS PHONE FAX NUMBER ZIP CODE $30 Each $20 Each $30 Each If this application is for a common carrier (plane, boat, railroad car, etc.) commencing operations in Minnesota for the first time, give the date operations will begin. An intoxicating liquor, 3.2% malt liquor and/or Sunday license is required for the first carrier to be operated in Minnesota. For each additional carrier a duplicate intoxicating, 3.2% malt liquor and/or Sunday license is required. Give the number of carriers requiring intoxicating, 3.2% malt liquor or duplicate intoxicating liquor licenses. Give the number of carriers requiring Sunday intoxicating, 3.2% malt liquor or duplicate Sunday intoxicating liquor licenses. All statements and documents submitted with this application shall become a permanent part of the record. The Liquor Control Director has the right to reject or revoke any license or license application containing a false statement. All records pertaining to purchase and sales shall be kept at the company's main office for a period of four years. Print Full Name of Applicant and Title Signature of Applicant DOB SSN Date MAKE CHECK PAYABLE TO: DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT * Office of Enterprise Technology AMOUNT RECEIVED American LegalNet, Inc. www.FormsWorkFlow.com