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 American LegalNet, Inc. www.FormsWorkFlow.com