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 FOR A BROKER TO REPRESENT A DISTILLERY, WINERY OR AN IMPORTER FEDERAL TAX ID # I _________________________________________as _____________________________________________ Name Title STATEMENT OF REPRESENTATION for ________________________________________________________________________have a contractual Distiller, Winery or Importer agreement with _____________________________________________________________________________ Name of Broker to represent and promote our products. This agreement is effective from ________________________to _________________________ I understand that under Minnesota Statutes §340A.317: A broker may promote a vendor's product and may call upon licensed retailers to insure product identification, give advance notice of new products or product changes and to share pertinent market information. A distiller, winery or importer is responsible for the actions of the broker. The Commissioner of Public Safety may suspend for up to sixty days the license of a distiller or winery on a finding that its broker and/or an employee of the broker has violated any provision of Minnesota Liquor Laws or rule of the commissioner relating to alcoholic beverages. Signature PS 02081 (12/98) DOB Social Security # Date American LegalNet, Inc. www.FormsWorkFlow.com