Mail to: New York State Liquor Authority Brand Label Registration Unit 80 S. Swan Street Suite 900 Albany, NY 12210-8002 (518) 474-6820 Application for: State of New York Executive Department STANDARD Brand Label / Tap Sign Registration (BEER) (ABCL 107-a and 9 NYCRR 84) For PRIVATE label brands: use Form 650.1 Division of Alcoholic Beverage Control Every brand of beer sold in New York State must be registered with the NYS Liquor Authority. This application must be filed IN DUPLICATE by the brand owner, if licensed in the state of New York or, if not licensed in the state New York, by the New York State licensed Beer Wholesaler who is appointed as the exclusive brand agent. This application must be accompanied by: (A) Copy of the Federal Certification/Exception of Label/Bottle Approval (CoLA) issued by the United States Department of the Treasury, Tax and Trade Bureau. The CoLA must be in complete conformity with the set of labels submitted and the information set forth by the applicant in this application. (This is not required for Tap Sign Registration). (B) One complete set of all labels (face, back, neck, etc.) which will appear on containers of the specified brand of beer, securely affixed to the reverse side of one of the application forms. (This is not required for Tap Sign Registration). (C) A check in the amount of one hundred fifty dollars ($150) made payable to the NYS Liquor Authority. (EXCEPTION: There is no fee due for brand label applications where the applicant has answered “YES” to question 15 AND “LESS THAN” to question 16 below). (D) Proper letter of authorization (signed and dated) designating the applicant as the “New York State exclusive brand agent” if the applicant is not the brand owner. 1. 2. Name of Wholesale Licensee Filing this Application Licensee’s Serial Number (7 digit) 3. Licensee’s Telephone Number ( ) - Ext. 4. Premise Address of Wholesale Licensee Filing this Application 5. Post Office Address (if different) 6. Brand Name of Beer (or name used on Tap Sign) 7. Class: (Beer, Ale, Porter, etc.) 9. Name, Trade Name and Address of Brand Owner (If Brand Owner is a RETAIL licensee, such licensee must file an application for a PRIVATE brand label using Form 650.1) 10. Name, Trade Name and Address of Brewer 12. Will this brand of beer be put in bottles, cans, kegs or other type of container or package at the brewery (or brewery portion of the licensed premises) for distribution and sale? Country of Origin Name, Trade Name and Address of Sole United States Agent, if any 11. 8. ► 13. Will this product be sold by ONE Retailer EXCLUSIVELY? 14. Will ALL of this brand of beer be sold EXCLUSIVELY through a Vat–to–Tap system on the licensed premises? 15. Will ALL the quantity of this brand of beer be produced by the applicant on the licensed premises? 16. The quantity of this brand of beer that will be produced by the applicant in a single calendar year: ► Yes No will be MORE THAN fifteen hundred barrels No Yes If you answered “Yes” to Question 13 , DISCONTINUE WORK ON THIS APPLICATION. The Brand Owner selling at Retail in NY must file an application for a PRIVATE Brand Label (Form 650.1) Yes No Yes No will equal or be LESS THAN fifteen hundred barrels ANY CHANGE IN THE LABELS OR IN ANY OF THE INFORMATION PROVIDED IN THIS APPLICATION MUST BE REPORTED TO THE STATE LIQUOR AUTHORITY WITHIN TEN DAYS AFTER SUCH CHANGE By my signature, I certify that I am the licensee filing this application, or that I have been duly authorized by the licensee to file this application; that I know the contents of this application; and that the statements contained in this application are true to my own knowledge. _________________________ _______________________________________________________ Title Signature _________________________ _______________________________________________________ Date Print (name of person whose signature appears above) ▼ For use by State Liquor Authority ▼ Approved / Disapproved Registration No. Class No. Fee Audited by Form 650 (3/07) Standard Brand Label - BEER American LegalNet, Inc. www.FormsWorkflow.com