NORTH CAROLINA ALCOHOLIC BEVERAGE CONTROL COMMISSION (919) 779-0700 Location: 400 East Tryon Road Raleigh, NC 27610 Mail: 4307 Mail Service Center Raleigh, NC 27699-4307 KEG PURCHASE-TRANSPORTATION PERMIT Date of Issue*: ______________________ Business Name: ______________________________________________________________________________ Business Address: _________________________________ City: ______________________ State: ________ Name of Purchaser: __________________________________________________________________________ Address of Purchaser: ________________________________ City: _____________________ State: ________ Identification Number: ______________________________ State of Issue: _____________ (Acceptable forms of ID are a driver’s license, North Carolina or military ID or passport) Destination of Keg(s):Address: ________________________________ City: __________________ State: ____ Total Number of Kegs Purchased: ___________ Purchaser must initial and sign below: 1. I understand and acknowledge that it is unlawful to provide alcoholic beverages, including the contents of the keg that I am purchasing, to any person under the age of 21. _______ (Initial) 2. I understand and acknowledge that I could be imprisoned or fined for providing alcoholic beverages to any person under the age of 21. _______ (Initial) 3. I understand that this permit must be displayed to any law enforcement officer upon request. _______ (Initial) __________________________________________________ (Purchaser’s Signature) ___________________________________________________ (Authorized Employee Signature) * Retailers are required to keep this permit on file for 90 days from the date of issue. At the written request of any individual, a retailer must retain the permit for a specified period of time beyond the 90 days but not longer than 180 days. Rev. 11/3/2010 American LegalNet, Inc. www.FormsWorkFlow.com