NORTH CAROLINA ALCOHOLIC BEVERAGE CONTROL COMMISSION AMOUNT FEE PAID: DATE: RECEIVED BY: TEMP #: Location: 400 EAST TRYON ROAD RALEIGH, NC 27610 (919)779-0700 APPROVED . . . . . . . . . . . . . . . . . . . . REJECTED . . . . . . . . . . . . . . . . . . . . . BY: DATE: (Do Not Write Above This Line) VENDOR REPRESENTATIVE PERMIT APPLICATION A certified check, cashier's check, or money order, made payable to the North Carolina Alcoholic Beverage Control Commission in the amount of $50.00 must be submitted with this application. County: (North Carolina Vendors only. County in which wholesaler is located) Vendor Name Company (winery, brewery, importer or nonresident vendor) that you represent Location Address of Vendor Street/Route City State Zip Code Mailing Address of Vendor Street/Route/PO Box City State Zip Code Applicant's Complete Name First (no abbreviations) Middle City Last State Zip Code Applicant's Resident Address Street/Route Business Address, if different than above Street/Route City State Zip Code Date of Birth Home Telephone # ( ) Email Address Business Telephone # ( ) Do you hold any financial interest in, or do you receive, any profits or salary from any retail malt beverage or wine outlet in North Carolina? Yes No If yes, explain on reverse side. I certify under oath or affirmation that I am not less than 21 years of age; that I have not been convicted of a felony within the past three years, and if convicted of a felony before then, I have had my citizenship restored; that I have not been convicted of an alcoholic beverage or misdemeanor controlled substance offense within the past two years, and that I have not had any alcoholic beverage permit revoked within the past three years. Signature of Applicant Date Sworn to and subscribed before me this the Day Month Year My commission expires: ____________ Date of expiration Notary or other person qualified by law to administer oaths Note: Must be stamped or sealed by notary 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 American LegalNet, Inc. www.FormsWorkFlow.com