Application Alcohol Processing Permit return to Alcoholic Beverage Control Division Permit Department P. O. Box 540 Madison, MS 39130-0540 1 American LegalNet, Inc. www.FormsWorkFlow.com Instructions Please read instructions prior to completing this form. The applicant's signature must be notarized by a licensed notary public. Submit either an original application for a sales tax number, a copy of the sales tax application, or if already granted a sales tax number, list the number in item ii of the application form. Provide on this application form the ownership classification of the applicant, whether a sole owner, partnership, corporation, limited liability company, trust or other. Note the instructions on who must file qualifying documents (Personal Record, Form 1001). Be sure to complete the permittee certification and oath ending this portion of the application. Each manager applicant must submit two (2) fingerprint cards with this application. The applicant must be fingerprinted by a law enforcement officer on ABC "applicant" fingerprint cards. The cards must be complete, legible, and capable of being classified by the Federal Bureau of Investigation. Some law enforcement agencies have ABC fingerprint cards on hand. If you need fingerprint cards, contact the Permit Department or visit your local MS Department of Revenue District Office. Submit certified funds in the amount of $32.00 per person payable to the "ABC-ff" with this application to cover the cost of processing your fingerprint cards. Your Mississippi Income Tax filing status, if applicable, will be verified for the past three (3) years. If our records indicate that you are delinquent in filing these returns (or you are indebted to the State of Mississippi for any other taxes or fees), you will be notified and must obtain clearance from your local Department of Revenue District Office before we can continue processing your application. Complete the waiver and authorization to release information. This release will assist us in verifying the information on your application. You are required to publish notice of your application in two (2) consecutive issues of a newspaper published in the town in which the business will be located. If no local newspaper exists, the notice may be published in the newspaper produced in the town located nearest your business and within the same County. The notice must be published in its entirety in ten point bold face type. An acceptable legal notice format is included in this packet. Submit with this application a publisher's affidavit (obtained from the newspaper) as proof of publication. You must include a check for $25.00 payable to ABC for your Permit fee. 2 American LegalNet, Inc. www.FormsWorkFlow.com (08/13) Permit Department use only Check number Permit number Alcohol Processing Permit Application I. Applicant: (Name of Sole Owner, Partnership, Limited Liability Company, or Corporation) Mailing Address: (Street / Post Office Box) (City) (State) (Zip) II. Business: (Trade Name) Address: (Street) (City) (Zip) County: III. Type of applicant entity: Sales Tax Number Sole Owner Partnership Trust Corporation Limited Liability Company Other IV. Have you or any member of your partnership, LLC, association, or any officer, director, or stockholder of your corporation, ever been convicted of any of the following: (answer each question) A felony, regardless of its nature, in any State of federal court? Yes No A violation of the local option alcoholic beverage control laws? Yes No A violation of any other law relating to alcoholic beverages, beer or light wine? Yes No A violation of any drug related law? Yes No If you answered "yes" to any of the above, explain fully: 3 American LegalNet, Inc. www.FormsWorkFlow.com V. How are alcoholic beverages used, or planned to be used, as an integral ingredient in your manufacturing process? (attach additional explanation if needed) ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ . VI. Anticipated total amount, in gallons, of alcoholic beverages used in your manufacturing process annually: VII. Will this business be operated as a sole ownership by the person applying for this Permit? Yes No If "yes," submit a Personal Record (Form 1001) with this application. VIII. Will this business be operated as a partnership? Yes No If "yes," submit a Personal Record Form 1001), with this application. Each partner must submit a Personal Record Form 1001 with this application. Submit a copy of the partnership agreement with this application. Partner Name Home Address Amount of Interest Owned ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ 4 American LegalNet, Inc. www.FormsWorkFlow.com IX. Will this business be operated as a corporation? Yes No If "yes," list the total amount of stock: Common Stock: Preferred Stock: Include a copy of the corporate charter Each officer, director, and stockholder owning 10% or more of the company's stock must submit a Personal Record Form 1001 List each officer, director, and stockholder of the company. Name Corporate Title Address Shares owned ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________