Form 47-264 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’ REPRESENTATIVES S OR CONTROL STATE MANAGER Manufacturer’ Name: s Address: Brands to be Marketed and Shipping Point(s) for Each Brand: Representative to be registered: (Executive Officer or Control States Manager) Name: Title: Business Address and Telephone No.: Home Address and Telephone No.: Length of time employed by manufacturer: Previous experience in sales and distribution of alcoholic beverages: Extent of authority to commit or contract in behalf of manufacturer: We certify as manufacturer, distiller, distributor, rectifier, or importer that our official representative named above will, at all times, comply with the Mississippi Laws and Policies and Regulations of the Mississippi State Tax Commission. We further certify that the representative has been informed relative to the Laws of the State of Mississippi and the policies and regulations of the Mississippi State Tax Commission. DATE EXECUTIVE OFFICER, TITLE American LegalNet, Inc. www.FormsWorkflow.com