STATE OF NORTH CAROLINA ALCOHOLIC BEVERAGE CONTROL COMMISSION Mailing Address: 4307 Mail Service Center Raleigh, North Carolina 27699-4307 Phone: 919-779-0700 FAX: 919-661-5927 APPLICATION FOR DISTILLER PERMIT FOR SPIRITUOUS LIQUOR Please Provide the Following Required Information: Firm Name: Address: (Name) (Phone Number) (Street Address, City, State , Zip Code) Nature of Business: (Distiller, Importer) Location of Plant(s) Where will shipments originate? Federal Basic Permit Numbers in other states and Types (This is required.) North C li Di till Broker R N th Carolina Distiller B k Representative: t ti (Name) (Street Address, City, State , Zip Code) Do you have a Certificate of Authority from the N.C. Secretary of States Office? Y N (Phone Number) In Process Are any of your employees related in any way to any Commission/ABC Board Member or Employee? OTHER REQUIRED DOCUMENTS: Firm Name: Federal Basic Permit for North Carolina By: (To be signed by an Executive Officer) Certificate of Authority for North Carolina Send this completed Distiller App form to address above: Pricing Division, Attn: Cathy Horne Date E-Mail Address: Print Name: Title: (Revised 9/2006, Formerly VENDOR APPLICATION FOR PERMIT) 5/21/2010 American LegalNet, Inc. www.FormsWorkFlow.com 5/21/2010 American LegalNet, Inc. www.FormsWorkFlow.com