Authorization # Approved NORTH CAROLINA ALCOHOLIC BEVERAGE CONTROL COMMISSION Phone (919) 779-0700 Rejected By APPLICATION FOR APPROVAL OF COMMON CARRIER Date To be completed by the common carrier's authorized official. (Do Not Write Above This Line) I hereby make application to the North Carolina Alcoholic Beverage Control Commission for approval as a Common Carrier pursuant to North Carolina General Statute 18B-1001.1 (c) and (d). Name of Common Carrier Mailing Address City Street/Route/PO Box State Zip Code Authorized Official's Full Name Middle First (no abbreviations) Last Position Held: Business Telephone # Day Time Telephone # Email Address Fax # I CERTIFY UNDER OATH OR AFFIRMATION THAT: - The information on this application is correct to the best of my knowledge. - I understand that I can only engage in activities authorized by North Carolina General Statute 18B-1001.1(c)and (d). Signature of Applicant Date Sworn to and subscribed before me this the Day Month Year My commission expires Date of expiration Signature of notary or other person qualified by law to administer oaths Note: Must be stamped or sealed by notary N.C.G.S. 18B-1001.1 (c) The direct shipment of wine by wine shipper permittees made pursuant to this section shall be by approved common carrier only. Each common carrier shall apply to the Commission for approval to provide common carriage of wines shipped by holders of permits issued pursuant to this section. Each common carrier making deliveries pursuant to this section shall: (1) Require the recipient, upon delivery, to demonstrate that the recipient is at least 21 years of age by providing a form of identification specified in G.S. 18B-302(d)(1). (2) Require the recipient to sign an electronic or paper form or other acknowledgment of receipt as approved by the Commission. (3) Refuse delivery when the proposed recipient appears to be under the age of 21 years and refuses to present valid identification as required by subdivision (1) of this subsection. (4) Submit any other information that the Commission shall require. All wine shipper permittees shipping wines pursuant to this section shall affix a notice in 26-point type or larger to the outside of each package of wine shipped within or to the State in a conspicuous location stating: 'CONTAINS ALCOHOLIC BEVERAGES; SIGNATURE OF PERSON AGED 21 YEARS OR OLDER REQUIRED FOR DELIVERY'. Any delivery of wines to a person under 21 years of age by a common carrier shall constitute a violation of G.S. 18B-302(a)(1) by the common carrier. The common carrier and the wine shipper permittee shall be liable only for their independent acts. (d) A wine shipper permittee shall be subject to jurisdiction of the North Carolina courts by virtue of applying for a wine shipper permit and shall comply with any audit or other compliance requirements of the Commission and the Department of Revenue." FORWARD THIS APPLICATION TO: If sending by U.S. Postal Service (regular mail) NC ABC COMMISSION ATTN: PRODUCT COMPLIANCE DIVISION 4307 MAIL SERVICE CENTER RALEIGH NC 27699-4307 If sending by U.S. Postal Service EXPRESS MAIL, FEDEX OR UPS: NC ABC COMMISSION ATTN: PRODUCT COMPLIANCE DIVISION 3322 GARNER ROAD RALEIGH NC 27610 NC Common Carrier 9/2003 American LegalNet, Inc. www.FormsWorkflow.com