Minnesota Department of Public Safety ALCOHOL AND GAMBLING ENFORCEMENT DIVISION 444 Cedar Street/Suite 222 St. Paul, MN 55101-5133 (651) 201-7500 TDD (651) 282-6555 FAX (651) 297-5259 WWW.DPS .STATE.MN.US BREW PUB BRAND REGISTRATION APPLICATION New Label Fee $40 EACH APPPROVED DENIED DATE NAME AND ADDRESS OF THE LICENSED REGISTRANT E-MAIL ADDRESS: AS PER MINNESOTA RULE 7515.0810 PLEASE ENTER THE NAME OR COMPANY THAT OWNS THIS BRAND LABEL: BRAND NAME CLASS AND TYPE BEER ALCOHOL % BY WEIGHT________________________ MN Statute 340A.301, Subd. 6 (d) Brewers who also hold one or more retail on-sale licenses and who manufacture fewer than 3,500 barrels of malt liquor in a year, at any one licensed premises, the entire production of which is solely for consumption on tap on the licensed premises or for off-sale from that licensed premises. A brewer licensed under this clause must obtain a separate license for each licensed premises where the brewer brews malt liquor. A brewer licensed under this clause may not be licensed as an importer under this chapter 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 Amount $40 ADDITION/REPLACEMENT No Charge Original Label #_________________ MAKE CHECK PAYABLE TO: DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT 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, whichever is greater, plus interest and attorneys fees. MS 604.113 PSO9083 (12/09) American LegalNet, Inc. www.FormsWorkFlow.com Brand Label Registration Requirements 1. 2. For malt beverages, indicate the alcoholic content by weight on a statement. The application must be typed or printed and signed in ink. Please answer all question, leave no blank spaces. Each product to be registered must be on a separate form and accompanied by a $40 fee. A copy will be returned to you when approved. Each registration must include an original label or a legible color copy affixed to the front of the form. Oversized labels may be attached to a separate sheet of paper stapled to this form. In the case of can beer, submit a photocopy of the can flat layout including the lid. Do not submit metal flats or 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. Paper clips may not be used to affix labels to this form. Attach one copy of the approved ATF form 5100.31 for each label submitted for our files. The name and address shown on the label must conform to the requirements of the Federal Alcohol Administration Act and the name appearing on the label must be identical with the name of the applicant. If the name on the label differs from the name of the applicant, a copy of the Federal Basic Permit showing the approval of the trade name or DBA must be furnished. The Commissioner may require a chemical analysis or samples of any product to be registered. If required, the applicant will be notified. A label registration remains active while the license of the registrant is valid and the product is shipped into Minnesota at least once every three years. If the product is not shipped in a three year period, the registration expires and must be re-registered. 3. 4. 5. 6. 7. Additions or Replacement Labels 8. Registrants should report additions and replacements on this form. There is no charge for additions or replacements. Do not submit replacement labels for changes in vintage. MS §3430A.311 requires all brand labels to be renewed with a fee of $30 payable every three years if you intend to continue to ship the product into Minnesota. A separate list of all brand labels due for renewal will be included with your annual license renewal form. 9. American LegalNet, Inc. www.FormsWorkFlow.com