NEW HAMPSHIRE LIQUOR COMMISSION APPLICATION FOR REGISTRATION The Undersigned ____________________________________of the city of __________________ Name of Company Location in the State of ___________________hereby requests that the application of ____________________________for registration as the Liquor Wine Representative of this company Name of Liquor wine Representative be granted. We certify: a. That to the best of our knowledge the information given by the applicant is true and correct; b. That to the best of our knowledge the applicant is honest, truthful, of good reputation and has never been refused registration as a representative of a distiller or wine manufacturer in any state or had such registration cancelled and that his is entirely worthy of being granted a registration; c. That he is entitled to enter a liquor store in the State only with specific permission of the Commission and then only for purposes of sales promotions and to secure information on inventory movement; d. That the applicant has been advised: 1. that he is to conduct himself as our representative strictly in accordance with the relevant provisions of the New Hampshire Liquor Commission and the regulations made there under and directions issued by the Commission from time to time; 2. that he may call upon licensed premises to promote the listed product he represents. If samples are given, they must have been purchased from a New Hampshire retail store. Samples are restricted for this use only; e. that we will notify the Board immediately if the applicant ceases to be employed by our company. ______________________________ Name of Company ______________________________ Signature of Officer ______________________________ Title __________________________SS Date____________________ Personally appeared before me____________________________ known to be the person Signing Officer of Company who executed the above affidavit and made oath that the same is true. _______________________________ Justice of Peace or Notary Public American LegalNet, Inc. www.FormsWorkflow.com