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 SUPPLIER PERMIT FOR SPIRITUOUS LIQUOR Please Provide the Following Information: Firm Name Address: (Name) (Street Address, City, State , Zip Code) (Phone Number) Nature of Business (Distiller, Importer) Location of Plant(s) Where will shipments originate? Federal Basic Permit Numbers and Types (This is required.) (This required.) North Carolina Supplier Broker Representative (Name) (Street Address, City, State , Zip Code) Do you have a Certificate of Authority from the N.C. Secretary of States Office? Y (Phone Number) N In Progress ___________ Are any of your employees related in any way to any Commission/ABC Board Member or Employee? Firm Name By (To be signed by an Executive Officer) G.S.18B-1105(a)(2) (Revised 7/28/2010) Date Print Name: Title: ______________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com