STATE OF NEW JERSEY DEPARTMENT OF LAW AND PUBLIC SAFETY DIVISION OF ALCOHOLIC BEVERAGE CONTROL P.O. BOX 087, 140 EAST FRONT STREET TRENTON, NJ 08625-0087 APPLICATION FOR SPECIAL PERMIT FOR HOME MANUFACTURE OF MALT ALCOHOLIC BEVERAGES [BRW] This permit will authorize the home manufacture of up to 200 gallons of malt alcoholic beverages (beer, ale, stout, porter) for Product manufactured under the personal consumption only. authority of this Permit may not be sold nor may it be used for any purpose other than personal consumption at the address which appears below, by the permittee, his/her family and their bona-fide guests. This application must be accompanied by a fee of $15.00 in the form of a Money Order or Check payable to the Division of A.B.C. 1. Full Name of Applicant_______________________________________ 2. Applicant’s Social Security No.______________________________ 3. Age of Applicant_________ 5. Permanent Residential Address of Applicant___________________ 4. Place of Birth_________________ _____________________________________________________________ 6. Applicant’s Telephone No.( )_____________________________ 7. If malt alcoholic beverages will not be brewed at above address, please state name, address and license number of premises where you will conduct your brewing activity: _____________________________________________________________ _____________________________________________________________ 8. Do you have an interest in any New Jersey alcoholic beverage license, either as owner or employee? If so, identify the license and the exact nature of such interest: _____________________________________________________________ _____________________________________________________________ Date______________________ __________________________________ Signature of Applicant 01/08 American LegalNet, Inc. www.FormsWorkflow.com