Minnesota Department Of Public Safety ALCOHOL AND GAMBLING ENFORCEMENT 444 Cedar Street - Suite 222 St. Paul, MN 55101-5133 (651)201-7507 TDD (651)282-6555 Fax (651)297-5259 BREWER NOTIFICATION TO FURNISH MALT LIQUOR FOR SAMPLING ______________________ ______________________________________________________ Date of Notification Name and title of person completing this notification & contact phone # BREWER INFORMATION __________________________________________________________________________________________ Brewer Name __________________________________________________________________________________________ Brewer Address __________________________________________________________________________________________ Brand name of product to be sampled __________________________________________________________________________________________ Amount of product to be provided __________________________________________________________________________________________ Name of Wholesaler that will make delivery __________________________________________________________________________________________ Number of times a product has been provided to this retailer for sampling in the past calendar year RETAILER INFORMATION __________________________________________________________________________________________ Retailer conducting sampling __________________________________________________________________________________________ Retailer address ____________________________________ ________________________________________________ Sampling date Hours The brewer named in this notification acknowledges the provisions of M.S. §340A510 and agrees to comply with all requirements. __________________________________________________________________________________________ Signature (Authorized brewer representative acknowledging above information to be true and correct). NOTE: All information to be completed by brewer representative PS009104 (12/09) American LegalNet, Inc. www.FormsWorkFlow.com