Department of Public Safety ALCOHOL AND GAMBLING ENFORCEMENT DIVISION 444 Cedar Street/Suite 133 St. Paul, MN 55101-5133 (651) 201-7506 TDD (651) 296-6555 FAX: (651) 297-5259 APPLICATION FOR WINE AND/OR DISTILLED SPIRITS IMPORTER'S LICENSE (FEE: $420) LICENSE EXPIRATION DATE: LICENSE #: DATE APPROVED: MINNESOTA TAX ID # LICENSEE'S NAME FEDERAL TAX ID # DBA OR TRADE NAME STREET ADDRESS LICENSE PERIOD FROM CITY STATE TO ZIP CODE PHONE FAX: YOU ARE APPLYING TO IMPORT (CHECK ONE) WINE DISTILLED SPIRITS ( ( BOTH ) ) LIST OTHER STATES WHERE LICENSED______________________________________________________________________ DO YOU HAVE AN INTEREST IN ANY RETAIL LICENSES? YES_____ NO_____ If yes please provide name and address. We hold valid and currently effective Federal Basic Qualifying Documents as provided by Alcohol Administration Act of August 29, 1935 (Title 27 U.S. Code, Section 203). We agree to comply with the Minnesota Excise Tax and alcoholic beverage laws and regulations. Names of the licensee's Minnesota Wholesalers. PRINT/TYPE FULL NAME OF APPLICANT SIGNATURE OF APPLICANT DOB DATE All Labels must be approved by Alcohol and Gambling Enforcement before an alcoholic beverage may be imported into Minnesota. MAKE CHECK PAYABLE TO: DIRECTOR OF ALCOHOL AND GAMBLING ENFORCEMENT AMOUNT RECEIVED NOTICE A $30.00 service charge will be added to all dishonored checks. You may also be subjected to a civil penalty of $100.00 or 100% of the value of the check, whichever is greater, plus interest and attorneys fees. MS 604.113 PS 09009 (05/06) American LegalNet, Inc. www.FormsWorkflow.com