Application For Primary American Source Registration
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Application For Primary American Source Registration Form. This is a Missouri form and can be use in Alcohol And Tobacco Control Statewide.
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Tags: Application For Primary American Source Registration, Missouri Statewide, Alcohol And Tobacco Control
MISSOURI DEPARTMENT OF PUBLIC SAFETY
DIVISION OF ALCOHOL AND TOBACCO CONTROL
APPLICATION FOR PRIMARY AMERICAN SOURCE REGISTRATION
NAME OF APPLICANT
MISSOURI LICENSE NUMBER
STREET OR MAILING ADDRESS
CITY
STATE
ZIP CODE
The foregoing applicant entity hereby applies for registration approval pursuant to Section 311.275, RSMo, and hereby agrees to
comply with the provisions of the Missouri Liquor Laws and the Rules and Regulations promulgated by the Supervisor of Alcohol and
Tobacco Control under the authority of the law.
This registration approval is requested for the purpose of selling the following brands and labels of malt liquor,
spirituous and vinous beverages in the State of Missouri:
MALT LIQUOR
SPIRITUOUS
APPROVAL DATE
VINOUS (WINES)
RECEIVED DATE
ATTESTATION
, being duly sworn, deposes and says that he/she is duly authorized as
of
OFFICIAL CAPACITY
, to sign
NAME OF PRIMARY AMERICAN SOURCE OF SUPPLY
for and in behalf of the applicant, that said applicant is the Primary American Source as defined under Section 311.275, RSMo,
for the brands and labels listed herewith and that all statements contained in the application are true to his/her own
knowledge and made with the consent of the applicant.
NAME (PRINTED)
RETURN TO:
BY (OFFICIAL SIGNING)
DIVISION OF ALCOHOL AND TOBACCO CONTROL
P.O. BOX 837
JEFFERSON CITY, MO 65102
THIS APPLICATION MUST BE FILED IN DUPLICATE
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