ALCOHOLIC BEVERAGE CONTROL Form 47-264-11-1-1-000 (Rev. 11/13) Mail this Application TO: Alcoholic Beverage Control P.O. Box 540 Madison, Mississippi 39130-0540 APPLICATION FOR REGISTRATION OF MANUFACTURER'S REPRESENTATIVES OR CONTROL STATE MANAGER Manufacturer's Name:________________________________________________________________________ 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 Number:________________________________________________________ __________________________________________________________________________________________ E-Mail Address _____________________________________________________________________________ Home Address and Telephone Number: __________________________________________________________ __________________________________________________________________________________________ Length of Time Employed by Manufacturer: ______________________________________________________ Previous Experience in Sales and Distribution of Alcoholic Beverages: __________________________________ _____________________________________________________________________________________________ __________________________________________________________________________________________ Extent of Authority to Commit to Contract on 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 Laws, Rules and Regulations applicable to us as enforced and overseen by the Mississippi Department of Revenue. We further certify that we have been informed of such Laws, Rules and Regulations. 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). By:___________________________________________________________________________________ Name of Officer 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