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 MALT BEVERAGE IMPORTER'S LICENSE (FEE $1,600) LICENSE EXPIRATION DATE: ____________ LICENSE # _________________________DATE APPROVED ____________ FEDERAL TAX ID # I, ______________________________________ as ___________________________________________ , (Officer or Authorized Representative) in behalf of _______________________________ , Street Address __________________________________ , of the City of ______________________________ , State of ___________________ , Zip Code ___________ , Tel. No. (_____)___________ , Fax No. (_____)___________ , hereby apply for license to ship into and sell Malt Beverages to duly licensed Minnesota wholesale distributors pursuant to Minnesota Statutes, Chapter 340A, and Regulations of the Liquor Control Director for a period of one year from and after the ______ day of _________________ 20_____. We are duly licensed by the State of ______________________ in which our principal place of business as a brewer-wholesaler is located. We hold valid and currently effective Federal Basic Qualifying Documents as provided by the Federal Beer Regulations. We agree to comply with the Minnesota Excise Tax and Liquor Control Laws and Regulations issued. On the reverse side of this application we list the names and addresses of Minnesota Wholesale Distributors to whom we presently sell our products. Does your company have any interest in any retail alcoholic beverage licneses? Yes_____ No_____ If you answered yes please provide the names and addresses_________________________________________ I certify that I have read the above questions and that the answers are true and correct to the best of my knowledge. __________________________________________________________________________________________ PRINT FULL NAME OF APPLICANT AND TITLE SIGNATURE OF APPLICANT DOB DATE ALL LABELS MUST BE APPROVED BY THE ALCOHOL AND GAMBLING ENFORCEMENT BEFORE AN ALCOHOLIC BEVERAGE MAY BE IMPORTED INTO MINNESOTA MAKE CHECK PAYABLE TO: DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT AMOUNT RECEIVED PS 09017 (3/09) American LegalNet, Inc. www.FormsWorkFlow.com Names and addresses of the applicant's Minnesota Wholesalers Name _________________________ Street ___________________________ City ______________________ Name _________________________ Street ___________________________ City ______________________ Name _________________________ Street ___________________________ City ______________________ Name _________________________ Street ___________________________ City ______________________ Name _________________________ Street ___________________________ City ______________________ Name _________________________ Street ___________________________ City ______________________ Name _________________________ Street ___________________________ City ______________________ Name _________________________ Street ___________________________ City ______________________ Name _________________________ Street ___________________________ City ______________________ Name _________________________ Street ___________________________ City ______________________ Name _________________________ Street ___________________________ City ______________________ Name _________________________ Street ___________________________ City ______________________ Name _________________________ Street ___________________________ City ______________________ Name _________________________ Street ___________________________ City ______________________ Name _________________________ Street ___________________________ City ______________________ Name _________________________ Street ___________________________ City ______________________ Name _________________________ Street ___________________________ City ______________________ Name _________________________ Street ___________________________ City ______________________ American LegalNet, Inc. www.FormsWorkFlow.com