ALCOHOLIC BEVERAGE CONTROL Form 47-265-11-1-1-000 (Rev.11/13) Mail this Application TO: Alcoholic Beverage Control P.O. Box 540 Madison, Mississippi 39130-0540 APPLICATION FOR REGISTRATION OF MANUFACTURER'S EMPLOYEES AND/OR BROKERS WORKING IN THE STATE OF MISSISSIPPI In compliance with the provisions of Mississippi Administrative Code Title 35, Part II, Subpart 2, Chapter 11, we hereby submit this application for registering the following individual(s) as an employee and/or broker of our company. (1) Name of Employee or Broker: ______________________________________________________ Address:________________________________________________________________________ Describe Duties:_________________________________________________________________ Method of Compensation:__________________________________________________________ (Salary - Salary & Bonus � Compensation) (2) Name of Employee or Broker: ______________________________________________________ Address:________________________________________________________________________ Describe Duties:_________________________________________________________________ Method of Compensation:__________________________________________________________ (Salary - Salary & Bonus � Compensation) (3) Name of Employee or Broker: ______________________________________________________ Address:________________________________________________________________________ Describe Duties:_________________________________________________________________ Method of Compensation:__________________________________________________________ (Salary - Salary & Bonus � Compensation) (If additional space is needed in which to list employees, attach an additional sheet.) We hereby certify that the above-named employee(s) and broker(s), with the exception of the Manufacturer's Representative, is/are the only one(s) who is/are receiving any 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 Alcoholic Beverage Control Division of the Mississippi Department of Revenue. Finally, the person signing this Application certifies under oath that all the information contained in this document is true and correct and he or she has the authority to sign this document as the manufacturer or on behalf of the manufacturer and acknowledges that this Application is being signed under the penalty of perjury pursuant to Mississippi Code Annotated Section 27-3-83(5). ______________________________________________________________________________________ Name of Manufacturer By:___________________________________________________________________________________ Name of Individual Title Date P. O. Box 540 Madison, MS 39130 www.dor.ms.gov Phone: 601.856-1301 FAX: 601.856-1390 American LegalNet, Inc. www.FormsWorkFlow.com