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 WWW.DPS.STATE.MN.US BRAND LABEL REGISTRATION APPLICATION New Label Fee $40 EACH Addition/Replacement Label: No Charge APPPROVED DENIED DATE NAME AND ADDRESS OF THE LICENSED REGISTRANT (Registrant must hold a valid Minnesota Import License for products produced out of State of Minnesota) E-MAIL ADDRESS & PHONE NUMBER: AS PER MINNESOTA RULE 7515.0810 PLEASE ENTER THE NAME OR COMPANY THAT OWNS THIS BRAND LABEL: IF YOU ARE NOT THE OWNER OF THIS BRAND, DO YOU HAVE PERMISSION FROM THE BRAND OWNER TO REGISTER AND IMPORT THIS LABEL INTO MINNESOTA? BRAND NAME CLASS  YES  NO AND TYPE ALCOHOLIC CONTENT % BY WEIGHT________________________ AFFIX COMPLETE SET OF LABELS BELOW FOLLOW INSTRUCTIONS ON BACK I CERTIFY THAT ALL STATEMENTS MADE BY ME ON THIS APPLICATION ARE TRUE, COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE TITLE & FULL NAME OF APPLICANT OR AUTHORIZED REPRESENTATIVE SIGNATURE OF APPLICANT DOB DATE NEW LABEL $40 ADDITION/REPLACEMENT No Charge Original Label # _________________ MAKE CHECK PAYABLE TO: DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT Amount Received_________ NOTICE A $30.00 service fee 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, PSO9083 (5/06) whichever is greater, plus interest and attorneys fees. MS 604.113 American LegalNet, Inc. www.FormsWorkFlow.com BRAND LABEL REGISTRATION REQUIREMENTS For complete Rules & Regulations under MN Chapter 340A, please visit www.dps.state.mn.us. PLEASE FOLLOW DIRECTIONS FOR REGISTRATIONS LISTED BELOW. LABEL REGISTRATIONS THAT DO NOT CONFORM TO THE LISTED DIRECTIONS WILL BE RETURNED. 1. Complete the registration form in its entirety. Fill in all blanks. Registrant must hold a valid MN Import License for products produced outside the state of Minnesota. 2. For alcoholic beverages, fill in the percent (%) of alcohol by weight on the front of the form. 3. Register each new brand on a separate form accompanied by a $40.00 fee. 4. Each registration must include an original label or legible color copy affixed to the front of the form. Oversized labels may be stapled on a separate sheet of paper attached to this form. For malt beverage cans, submit a photocopy of the can flat including the lid. (Do not submit metal flats or actual lids or cardboard boxes for labels). Submit a photocopy stapled to the registration form of any non-paper labels that are etched on a bottle. Do not use paperclips to attach labels to this form. 5. Staple one copy of the FEDERAL LABEL APPROVAL FORM 5100.31 to the back of each label you register. (No paperclips) DO NOT SUBMIT EXTRA COPIES OF THE LABEL REGISTRATION APPLICATION. THE ALCOHOL & GAMBLING ENFORCEMENT DIVISION NO LONGER RETURNS PAPER COPIES AS CONFIRMATION OF BRAND REGISTRATION. Please visit our web site for brand label registration confirmation at http://www.dps.state.mn.us/age/BrandLabelSearch.aspx. 6. The name and address shown on the label must conform to the requirements of the Federal Alcohol Administration Act. The name on the label must match with the name of the licensed brand registrant. Please include a copy of your Federal Basic Permit and any trade names along with the brand label registration. 7. Brand label registrations are valid for three (3) years. A $30.00 renewal fee is required after the third year if a product continues to be shipped into Minnesota. A separate inventory list of all labels due for renewal will be sent along with a license holder’s annual license renewal application. This should help to eliminate the inconvenience of licensees having to keep track of individual brand label renewal dates. 8. Report size additions (Standard of Fill) and significant label design changes on a Brand Label Registration Form. There is no additional charge for this reporting requirement. 9. DO NOT REPORT CHANGES IN PRODUCT VINTAGE. 10. Brand label registrations for shipment into Minnesota are approved based upon the date of receipt by the Alcohol & Gambling Enforcement Division. American LegalNet, Inc. www.FormsWorkFlow.com