Form 47-265 Mail this Application To: Mississippi State Tax Commission Alcoholic Beverage Control Division P. O. Box 540 Madison, Mississippi 39130-0540 APPLICATION FOR REGISTRATION OF MANUFACTURER’ EMPLOYEES AND/OR BROKERS S WORKING IN THE STATE OF MISSISSIPPI Date: In compliance with the provisions of Regulation No. 31 of the Mississippi Alcoholic Beverage Control Laws, Rules and Regulations, we hereby submit this application for registering the following individual(s) as an employee and/or broker of our company. In addition, we have attached hereto a copy of the employee or broker contract now in effect. (1) Name of Employee or Broker: Address: Describe Duties: Method of Compensation: (Salary – Salary & Bonus – Commission) [Attach copy of written employee contract now in effect.] (2) Name of Employee or Broker: Address: Describe Duties: Method of Compensation: (Salary – Salary & Bonus – Commission) [Attach copy of written employee contract now in effect.] (3) Name of Employee or Broker: Address: Describe Duties: Method of Compensation: (Salary – Salary & Bonus – Commission) [Attach copy of written employee contract now in effect.] (If additional space is needed in which to list employees, attach an additional sheet.) We hereby certify that the above-named employees and brokers, with the exception of the Manufacturer’ s Representative, are the only ones who are receiving an direct or indirect compensation, profit or commission from the sale and distribution of our merchandise. We further certify that we have read and thoroughly understand all regulations and all other provisions of the Mississippi Alcoholic Beverage statutes and that all those employed have been informed relative to the laws, rules and regulations of the Mississippi Alcoholic Beverage Control Division. Name of Vendor By Title Date Sworn to and subscribed before me this the day of , 20 Notary Public My Commission Expires American LegalNet, Inc. www.FormsWorkflow.com