NORTH CAROLINA ALCOHOLIC BEVERAGE CONTROL COMMISSION AMOUNT FEE PAID: DATE: RECEIVED BY: TEMP #: Location: 400 E. TRYON ROAD RALEIGH, NC 27610 (919)779-0700 APPROVED . . . . . . . . . . . . . . . . . . . . REJECTED . . . . . . . . . . . . . . . . . . . . . BY: DATE: (Do Not Write Above This Line) WHOLESALE SALESMAN'S APPLICATION A certified check, cashier's check, or money order, made payable to the North Carolina Alcoholic Beverage Control Commission in the amount of $100.00 must be submitted with this application. County: (in which wholesaler is located) Date: Applicant's Complete Name First (no abbreviations) Middle Last Wholesaler Location Address of Wholesaler Street/Route City State Zip Code Mailing Address of Wholesaler Street/Route/PO Box City State Zip Code Applicant's Resident Address Street/Route City State Zip Code Date of Birth Home Telephone # ( ) Last 4 of Social Security # Business Telephone # ( ) If you are transferring from one branch location to another with the same wholesaler, please indicate the address from which you are transferring: 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 a resident of the State of North Carolina, or an applicant that has executed a power of attorney in accordance with G.S. 18B-900(a)(2)(b); 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 Sworn to and subscribed before me this the Day Month Year My commission expires: ____________ 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 E. TRYON ROAD RALEIGH NC 27610 American LegalNet, Inc. www.FormsWorkFlow.com FOR OFFICIAL USE ONLY Do not write below this line NORTH CAROLINA ALCOHOLIC BEVERAGE CONTROL COMMISSION INVESTIGATIVE REPORT County: Wholesaler: Application ID: Applicant's Complete Name (First, Middle, Last): Is individual filing application at least 21 years of age? Has individual ever held an ABC permit in N.C. before? Yes No Revoked Yes Suspended No Yes - If yes, was Permit ever No Has the individual ever been a member or a manager of a N.C. corporation that held ABC permits? Corporation Name: Is individual a bona fide resident of North Carolina? Yes File No.: No History of applicant's past operation and/or reputation (explain) Are there pending violations against this individual? Yes No If yes, explain: Local objection (see attached) Have you reviewed the application with the applicant to determine that it is complete and correct? Have you reviewed the application with the wholesaler to determine that it is complete and correct? Are there any reasons permits should not be issued to this applicant? Yes No If yes, explain: Yes Yes No No Agent's Signature Date Wholesale Salesman's Application Rev 01/08 American LegalNet, Inc. www.FormsWorkFlow.com