PLEASE Permit No. ________ Date Issued: _______ ATTACH North Carolina Alcoholic Beverage Control Commission A RECENT Mailing Address: 4307 Mail Service Center, Raleigh, NC 27699-4307 Location: 400 East Tryon Road, Raleigh, NC 27610 Phone: (919) 779-0700 Fax: (919) 661-5927 PHOTO Application for Brokerage Representative/ Salesman Permit for Spirituous Liquor Application Requirements: A. Include a recent photo B. Include a Criminal Record Check or a certified copy of a court record(s) from the last jurisdiction where you have maintained residence for one year or more. If there is no record, please have the clerk of the court in the jurisdiction so certify. C. This form MUST be Notarized (second page) 1. Name of the Brokerage you represent: Date of employment: _____________________________________________________________________ 2. Territory responsible for: _________________________________________________________________ 3. Name (PRINT): 4. Mailing Address: ________________________________________________________________________ 5. E-mail Address (Required): ______________________________________________________________ 6. Phone No: ( ) __________________________Driver's License No: __________________________ 7. Social Security No.– LAST FOUR (4) DIGITS. ______________Date of birth: ___________________ 8. Address of last place of residence for period of one year or more: __________________________________________________________________________________________ __________________________________________________________________________________________ 9. Spouse's Name (if applicable): _____________________________________________________________ Spouse's Address (if different from above): __________________________________________________ _________________________________________________________________________________________ 10. Are you (or your spouse) related to any state or local ABC Board Member or the employees thereof? ____Yes ____No If yes, Name, relationship, and their address. a. _______________________________________________________________________________________ b. _______________________________________________________________________________________ 11. Do you now or have you (or your spouse) previously held any type of permit(s) issued by the North Carolina Alcoholic Beverage Control Commission? If so, for each permit indicate the date and name of the business licensed, and, if applicable, the reason the permit is no longer held. a. _______________________________________________________________________________________ b. _______________________________________________________________________________________ Revised 4/2008 (Formerly Application for Spirituous Liquor Representative's Permit) 1 American LegalNet, Inc. www.FormsWorkFlow.com 12. Required: Previous employers - Name, address, telephone number, and dates of employment a. _______________________________________________________________________________________ b. _______________________________________________________________________________________ c. _______________________________________________________________________________________ 13. Provide name, address and telephone number of two (2) references: a. _______________________________________________________________________________________ b. _______________________________________________________________________________________ 14. Have you ever been convicted of violating any criminal law? ____Yes ____No If yes, give reason for conviction: _________________________________________________________________________________________ _________________________________________________________________________________________ 15. Attach a Criminal Record Check or a certified copy of a court record(s) from the last jurisdiction where you have maintained residence for one year or more. If there is no record, please have the clerk of the court in the jurisdiction so certify. By signing this request for a Brokerage Salesman Permit, you fully understand that, if issued, this permit can, at the discretion of the Commission, be revoked, suspended or annulled at any time. _____________________________________________________________________________________________ Signature Date Sworn to and subscribed before me on this the __________day of ________________20________ My commission expires: ____________________________________________________ __________________________________________ Notary Mail to: ATTN: Cathy Horne North Carolina ABC Commission 4307 Mail Service Center Raleigh NC 27699-4307 3/10/2011 2 American LegalNet, Inc. www.FormsWorkFlow.com