NORTH CAROLINA ALCOHOLIC BEVERAGE CONTROL COMMISSION Location: AMOUNT FEE PAID: DATE: 400 EAST TRYON ROAD RALEIGH NC 27610 (919)779-0700 APPLICATION: RECEIVED BY: MAIL TO ADDRESS AT BOTTOM OF PAGE APPLICATION FOR DUPLICATE PERMITS (Do Not Write Above This Line) A certified check, cashier's check or money order in the amount of $10.00, per location, wholesale salesman or vendor representative must be submitted with this application. PLEASE PRINT Reason for Duplicate Lost or Damaged Permittee Name Change (Check appropriate box) Trade Name Change Corporate Name Change LLC Name Change (Including marriage/divorce) Business Phone# ( (Submit new Articles) ) Type of Ownership (Check One ) Individual Limited Partnership Partnership Corporation Limited Liability Company County in which Business is Located Current or New Trade Name of Business Location Address of Business Street/Route City State Zip Code Street/Route/PO Box City State Zip Code Middle Last Mailing Address of Business If incorporated, Corporate Name If LLC, LLC Name Individual's Full Name First (no abbreviations) Former Trade Name (If application is for trade name change) Former Corporate Name (If application is for corporate name change) Former LLC Name (If application is for LLC name change) Permit(s) Currently Held Date Signature MAIL THIS APPLICATION TO: If sending by US Postal Service (regular mail): If sending by US Postal Service EXPRESS MAIL or by FEDEX / UPS: NC ABC COMMISSION 4307 MAIL SERVICE CENTER RALEIGH NC 27699-4307 NC ABC COMMISSION 400 EAST TRYON ROAD RALEIGH NC 27610 Application for Duplicate Permits Rev 11/2010 American LegalNet, Inc. www.FormsWorkFlow.com