MISSOURI DEPARTMENT OF PUBLIC SAFETY DIVISION OF ALCOHOL & TOBACCO CONTROL PO Box 837 Jefferson City, Missouri 65102 1738 E. Elm Street Jefferson City, Missouri 65101 Telephone 573-751-2333 FAX 573-526-4540 Permit No. Date SALESMAN PERMIT APPLICATION Name (LAST, FIRST, MIDDLE) Maiden (if applicable) Address ( City ) ( Home Telephone State ) Work Telephone Social Security No. Date of Birth Height Weight Sex Hair Eyes Company you will be representing Doing Business As License No. Address City State Have you ever been issued a salesman permit before? No Zip Yes If you answered “YES” please give name of company(ies) you represented. Employment history for last five (5) years Have you ever been convicted of a Non-intoxicating Beer Law or a Liquor Control Violation? No Yes If “YES” give full details as to date, charge, place, sentence or disposition. Do you have any financial interest in, or hold any position or office in, a business that is licensed to sell intoxicating liqu or or non-intoxicating beer at retail? No Yes If you answered “YES” to any part of the previous question, please give full details. I certify that the answers I have given on this application are true and complete. I authorize the Supervisor of Alcohol and To bacco Control or his duly appointed agents access to any and all criminal records of the undersigned individual. Signature of Applicant District Record Check made through License Check made Supervisor of Alcohol and Tobacco Control District Supervisor American LegalNet, Inc. www.FormsWorkflow.com MO 812-1006N (12-07)