PERMIT Application for New York State Division of Alcoholic Beverage Control State Liquor Authority Plenary Miscellaneous Permit for Market Research Testing ABCL § 99-b.(1)(k) – Class MC 736 (One Occasion) (Page 1 of 5) This completed form, typed or neatly printed, MUST be on file and in the possession of the State Liquor Authority not less than THIRTY DAYS before the date of the Scheduled Market Research Test. In a separate letter, please set for a detailed description of the manner in which the Market Research Testing will be conducted. A PERMIT FEE OF $20.00 PLUS A FILING FEE OF $10.00 WILL BE REQUIRED FOR EACH DATE. Name of Market Research Company __________________________________________________________________________________________ Name of Building where the Market Research Test will be conducted ___________________________________________________________________________________ Street address and room where the Market Research Test will be conducted ___________________________________________________________________________________ ___________________________________________________________________________________ City, Town, or Village/ State / Zip ___________________________________________________________________________________ County of Market Research Test Location _______________________________________________ Name of the Contact Person at the Proposed Location ____________________________________________________ Room Number of the Contact Person at the Proposed Location ____________________. Telephone Number of the Contact Person at the Proposed Location Date of the Market Research Test / Day of Week: Time the Market Research Test will Start and End: . Date ____________________________________ Start Time __________________________ Day ____________________. End Time __________________________ Name of the Person who will Conduct the Market Research Test __________________________________________________________________ Permanent Business Address (Street Address and Room Number) of the Person conducting the Market Research Test: _______________________________________________________________________________ _______________________________________________________________________________ City, Town, or Village/ State / Zip _______________________________________________________________________________ Business Telephone Number of the Person conducting the Market Research Test ____________________________________________________ Name of the Market Research Company Official sending this form _______________________________________ Title of the Official sending this form _______________________________ Signature of the Market Research Company Official sending this form _____________________________________________________________ 03/25/11 American LegalNet, Inc. www.FormsWorkFlow.com PERMIT Application for New York State Division of Alcoholic Beverage Control State Liquor Authority Plenary Miscellaneous Permit for Market Research Testing ABCL § 99-b.(1)(k) – Class MC 736 (One Occasion) (Page 2 of 5) Please answer all questions. If “none” or “not applicable”, so specify. MARKET RESEARCH TESTING COMPANY 1. Full name of Person or Entity Applying to Conduct the Market Research Test: (If partnership, list all partners) 2. Trade Name: 3. Permanent Street Address of Person or Entity Conducting the Market Research Test: 4. City, Town, or Village, and Zip Code: 5. County where Located (if within New York State): 6. Telephone Number: 7. NYS Alcoholic Beverage License No. (if licensed): Date issued: 8. 19. 20. Post Office Address (if different from above): Has the applicant or (if partnership) any of the partners or (if a corporation) any of the officers, directors, or stockholders, or any agent or employee of the applicant, ever been CONVICTED (including pleas of guilty of suspended sentences) of any felony or of any other crime or offense of any kind except traffic violations? If you answered “Yes” to question No. 19, a copy of a Certificate of Conviction for each conviction, certified by the Court, must be attached. Have you attached the required copies? 21. Has any alcoholic beverage license or permit issued to the applicant or for any part of the building containing the premises where the market research testing will be held ever been revoked or cancelled? Answer “YES” or “NO”: If “Yes”, please attach a separate sheet providing detailed information of any or all such conviction(s). Answer “YES” or “NO” or “Not Applicable”: Answer “YES” or “NO”: If “Yes”, please attach a separate sheet providing detailed information of any or all such disciplinary action(s). American LegalNet, Inc. www.FormsWorkFlow.com PERMIT Application for New York State Division of Alcoholic Beverage Control State Liquor Authority Plenary Miscellaneous Permit for Market Research Testing ABCL § 99-b.(1)(k) – Class MC 736 (One Occasion) (Page 3 of 5) MANUFACTURER OF PRODUCT(S) BEING TESTED 1. (ATTACH ADDITIONAL SHEETS AS NEEDED) Full name of Manufacturer of the product(s) to be market research tested: (If partnership, list all partners) 2. Trade Name of the Manufacturer: 3. Permanent Street Address of the Manufacturer: 4. City, Town, or Village, and Zip Code: 5. County where Located (if within New York State): 6. Telephone Number: 7. NYS Alcoholic Beverage License No. (if licensed): Date issued: 8. Post Office Address (if different from above): STATE DISTRIBUTOR OF PRODUCT(S) BEING TESTED 1. (ATTACH ADDITIONAL SHEETS AS NEEDED) Full name of authorized Distributor importing the product(s) into New York State for the market research test: (If partnership, list all partners) 2. Trade Name of the Distributor: 3. Permanent Street Address of the Distributor: 4. City, Town, or Village, and Zip Code: 5. County in New York State where Located: 6. Telephone Number: 7. 8. NYS Alcoholic Beverage License No.: Date issued: Post Office Address (if different from above): American LegalNet, Inc. www.FormsWorkFlow.com PERMIT Application for New York State Division of Alcoholic Beverage Control State Liquor Authority Plenary Miscellaneous Permit for Market Research Testing ABCL § 99-b.(1)(k) – Class MC 736 (One Occasion) (Page 4 of 5) PRODUCT(S) BEING MARKET TESTED (ATTACH ADDITIONAL SHEETS AS NEEDED) Is Product Brand Label Registered in New York? 1. 2. 3. EXCISE TAX Which NYS licensed person or entity will pay the NYS alcoholic beverage Excise Tax? A COPY OF THE FEDERAL LABEL APPROVAL FOR EACH PRODUCT BEING TESTED MUST BE ATTACHED CONDUCT OF THE MARKET TEST (ATTACH ADDITIONAL SHEETS AS NEEDED) 1. State how the participants were recruited. Attach a copy of the advertisement(s) or solicitation(s) sent to the participants. 2. Will participants be paid for their participation? If so, how much. 3. Will a list of participants be maintained for a period of three years from the date of the test? 4. Will participants in the market research be required to show proper proof of age in conformity with ABCL § 65-b.(1)(b)? 5. Provide details regarding sample size and number of samples to be given to each participant. 6. Will food be provided? If “Yes”, please state the kinds and quantities of food to be offered. 7. What, if any, transportation is being provided for participants in the market research? American LegalNet, Inc. www.FormsWorkFlow.com PERMIT Application for New York State Division of Alcoholic Beverage Control State Liquor Authority Plenary Miscellaneous Permit for Market Research Testing ABCL § 99-b.(1)(k) – Class MC 736 (One Occasion) (Page 5 of 5) THIS CERTIFICATION TO BE SIGNED AND DATED BY THE MARKET RESEARCH TESTING COMPANY ___________________________________________________________________________________ certifies that (s)he is ________________________________________________________________________________________________ (Title) of the above named Market Research Company; that (s)he knows the contents of the above application and the statements and answers therein; that the same are true of his/her own knowledge; that (s)he has been authorized, by the applicant to make the statements and answers in this application with the same force and effect as if the applicant made such statements and answers itself. The undersigned certifies that he/she has read the terms and conditions for the permit applied for and agrees to comply with those conditions. ______________________________________________ _________________________________________________________ (Signature of authorized officer) (Street Address) ______________________________________________ _________________________________________________________ (Print Name) (City, Town, Village) ______________________________________________ _________________________________________________________ (Office Telephone Number) (Office Fax Number) (Zip Code) Completed applications and any supporting information should be mailed to: NEW YORK STATE LIQUOR AUTHORITY PO BOX 3796 NEW YORK, NY 10008-3796 American LegalNet, Inc. www.FormsWorkFlow.com