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 TO IMPORT FOR PERSONAL USE [PC] Application must be accompanied by a fee of $50.00, payable by Money Order or Check drawn to the order of the Division of Alcoholic Beverage Control. PRINT OR TYPE RESPONSES 1. Name of Applicant____________________________________________ 2. Home Address of Applicant____________________________________ _____________________________________________________________ 3. Telephone number where applicant can be contacted during business hours ( )________________________________________ 4. List below the alcoholic beverages requested to be authorized to import into New Jersey: BRAND NAMES 5. QUANTITIES (Number of cases, bottles, size of bottles) Supplier (from whom purchased) Name and Address _____________________________________________________________ _____________________________________________________________ 6. If alcoholic beverages are being transferred with household goods, give place of origin__________________________________ _____________________________________________________________ 7. Are these beverages to be imported solely for personal use? Yes___ No___ If no, state other purposes: _____________________________________________________________ _____________________________________________________________ OVER L American LegalNet, Inc. www.FormsWorkflow.com 8. Place of entry into USA______________________________________ 9. Indicate the vehicle or method of transport of the alcoholic beverages from place of entry to the New Jersey destination: (If personal vehicle, state make, model and plate number.) ____________________________________________________________ _____________________________________________________________ 10. Indicate address in New Jersey to which alcoholic beverage will be delivered:__________________________________________ _____________________________________________________________ 11. Date of delivery into New Jersey_____________________________ 12. Does the applicant have any ownership interest in a New Jersey liquor license of any type? Yes____ No____ If yes, provide license number______________________________________ 13. NOTE: ANY QUANTITY FOR WHICH A PERMIT IS REQUESTED AMOUNTING TO MORE THAN 5 CASES, 12 BOTTLES PER CASE OR 750 LITRE SIZE, MUST BE ACCOMPANIED BY A STATEMENT JUSTIFYING THE AMOUNT AS BEING FOR PERSONAL USE. EXPLANATION: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ If a Special Permit is granted, applicant certifies that the abovementioned alcoholic beverages will be used solely for personal use and not for resale of any commercial use, that applicant is not engaged or substantially interested in the liquor business, and that all limitations and conditions set forth in the Special Permit, and all rules and regulations promulgated heretofore and hereafter by the Director of the Division of Alcoholic Beverage Control pertaining to the importation of alcoholic beverages into the State of New Jersey will be followed. ___________________________ Date __________________________________ Signature of Applicant This Permit will not be issued until applicable New Jersey taxes have been paid. Applicants are advised to contact the Division of Taxation, P.O. Box 264, 5 Quakerbridge Plaza, Third Floor, Trenton, NJ 08695, (609) 588-3932. 01/07 American LegalNet, Inc. www.FormsWorkflow.com