FORMAT ACKNOWLEDGEMENT OF RECEIPT OF A WINE DELIVERY for an CARRIER CONFIRMATION OF IDENTIFICATION PRESENTED BY THE WINE RECIPIENT ACKNOWLEDGEMENT OF RECEIPT OF A WINE DELIVERY to be used by a Common Carrier when delivering Wine Sold and Shipped Directly to a New York Residential Customer for such Customer’s Personal Use and Not for Resale from a New York State Licensed Wine Manufacturer or from the holder of an Out-of-State Direct Shipper’s License issued by New York State CARRIER’S NAME CARRIER’S ADDRESS CARRIER ACCOUNT NUMBER ASSIGNED TO THIS WINERY-SHIPPER CARRIER DELIVERY NUMBER ASSIGNED TO THIS DELIVERY CARRIER’S NEW YORK STATE LICENSE NO. WINERY-SHIPPER’S NAME WINERY-SHIPPER’S ADDRESS WINERY-SHIPPER’S NEW YORK STATE OUT-OF-STATE DIRECT SHIPPER’S LICENSE NO. WINERY-SHIPPER’S HOME STATE WINERY LICENSE NO. WINERY-SHIPPER’S FEDERAL BASIC PERMIT NO. [As required by Alcoholic Beverage Control Law §§ 79-c.(3)(e)(ii), 79-d.(1)(e)(ii)] NAME OF PERSON RECEIVING ITEM ADDRESS OF PERSON RECEIVING ITEM TYPE OF IDENTIFICATION PRESENTED BY THE WINE RECIPIENT INSTRUCTIONS FOR COMPLETING THE ACKNOWLEDGEMENT OF RECEIPT Ņ Ņ CHECK ONE BOX IN EACH OF THE TWO COLUMNS BELOW, AND SPECIFY ADDITIONAL FACTS AS REQUIRED OF A WINE DELIVERY CARRIER CONFIRMATION OF IDENTIFICATION PRESENTED BY THE WINE RECIPIENT THE CARRIER MUST MAINTAIN AN ELECTRONIC OR PAPER RECORD DOCUMENTING THAT THE RECIPIENT OF THE WINE PRESENTED PROPER AND VALID IDENTIFICATION. ACCEPTABLE FORMS OF IDENTIFICATION New York State Ō (2) MAKE A RECORD OF THE TYPE OF IDENTIFICATION YOU EXAMINED. FOR EXAMPLE, IF A NEW YORK DRIVER’S LICENSE IS PRESENTED, CHECK THE FIRST BOX IN THE LEFT HAND COLUMN, AND THE FIRST BOX IN THE RIGHT HAND COLUMN. (3) SPECIFY ANY ADDITIONAL FACTS REQUIRED, SUCH AS THE NAME OF ANOTHER STATE, TERRITORY, COUNTRY, OR BRANCH OF ARMED FORCES. (4) RECORD THE DATE THE IDENTIFICATION PRESENTED WILL EXPIRE. (5) GET THE SIGNATURE OF THE PERSON RECEIVING THE WINE DELIVERY. (6) RECORD THE NAME OF THE EMPLOYEE MAKING THE DELIVERY. (7) RECORD THE TIME AND DATE OF DELIVERY. Other State ______________________________ (Specify) Valid Driver's License (1) EXAMINE THE IDENTIFICATION PRESENTED BY THE PROPOSED RECIPIENT. DO NOT ACCEPT A FORM OF IDENTIFICATION UNLESS YOU ARE FULLY FAMILIAR WITH ITS CONTENTS AND HAVE CAREFULLY COMPARED THE PHOTOGRAPH ON THE IDENTIFICATION WITH THE PERSON PRESENTING IT IDENTIFICATION WAS ISSUED BY (SPECIFY ADDITIONAL FACTS WHERE REQUIRED) Federal Government Valid Non-Driver Identification Card United States Territory, Commonwealth, or Possession Ō Ō Ō Ō District of Columbia Ō Ō Ō Ō The United States Government Ō Valid Passport Ō Valid Identification Card issued by the Armed Forces of the United States EXPIRATION DATE OF IDENTIFICATION PRESENTED / Month (Specify)______________________ Provincial Government of the Dominion of Canada Ō The Country of ___________________________ (Specify) Identify Branch of the Armed Forces _____________________ (Specify) SIGNATURE OF PERSON RECEIVING THE WINE DELIVERY / Day Year NAME OF THE EMPLOYEE MAKING THE WINE DELIVERY TIME OF DELIVERY DATE OF DELIVERY AM / PM Hour Minute Month / Day Year (Revised 09-30-05) American LegalNet, Inc. www.FormsWorkflow.com