NORTH CAROLINA ALCOHOLIC BEVERAGE CONTROL COMMISSION WINE SHIPPER PERMIT APPLICATION Application # Fee Paid: Date Rec'd: Rec'd By: (Do Not Write Above This Line) Approved Rejected By Date I hereby make application to the North Carolina Alcoholic Beverage Control Commission for a Wine Shipper permit. TYPE OF OWNERSHIP (Check One): Individual (complete sections A,E and F, below) Partnership (complete sections A, E and F, below) Corporation (complete sections A, B, E and F below) Section A Trade Name of Business Location Address of Business Street/Route City State Zip Code Limited Liability Company (complete sections A, C, E and F, below) Limited Partnership (complete sections A, D, E and F, below) Mailing Address of Business Street/Route/PO Box City State Zip Code Web Site address through which orders will be received: Section B If Incorporated, Corporate Name If 25% or more , stockholder is another business entity, name of entity: Section C If LLC, Company Name Form of Management: Member-Managed Manager -Managed If 25% or more interest holder is another business entity, name of entity: Section D If Limited Partnership, Limited Partnership Name: General Partner Name: Applicant's name and position in general partner business entity: Section E Describe the operation of this business: 1. Has disapproval ever been given by any government agency to any application or notice of intent to manufacture, use, store, rectify, bottle, distribute, sell, import or transport distilled spirits, beer or wine filed by any of the required applicants or any firm or corporation of which they were proprietor or a partner, officer, director, principle stockholder, or responsible employee? No If yes, explain on attachment. Yes 2. Have any of the required applicants or any firm in which you were a principal ever compromised, by payment of penalties or otherwise, any violation of any federal or state laws relating to internal revenue or customs taxation of alcoholic beverages? If yes, explain on attachment. Yes No 3. Does this business entity presently hold a valid Federal Basic Permit as a Bonded Wine Cellar or Bonded Winery? Yes No American LegalNet, Inc. www.FormsWorkFlow.com It is a Crime to make a false statement to obtain an ABC Permit Each of the required applicants certify under oath or affirmation that: - I am not less than 21 years of age. - I have not been convicted of a misdemeanor controlled substance offense nor an alcoholic beverage offense within the past two years. - 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. - Note: Conviction is defined as "A person who has been "convicted" and found guilty, or has entered a plea of guilty or nolo contendere, and for which a judgment has been entered." - I have had no alcoholic beverage permit revoked within three years. - I understand that I can only engage in activities authorized by the N.C. ABC Laws for the permit issued. - I am not an officer, director or affiliate and have no financial interest in, nor do I receive from or pay any profits or salary to any N.C. retail wine outlet except in the case of a NC winery holding retail permits as authorized by G. S. 18B-1101. - I understand that I can ship not more than 2 cases (18 liters) to any one individual per month. Section F OATH OF APPLICANT I certify as required by NCGS 18B-902(a) and (c) that this application and all attachments are true, correct, and complete to the best of my knowledge. Name of Applicant Signature of Applicant Sworn to and subscribed before me this the My commission expires Date of expiration Signature of notary or other person qualified by law to administer oaths day of Date of Birth Position in Business Entity , 20 . OATH OF APPLICANT I certify as required by NCGS 18B-902(a) and (c) that this application and all attachments are true, correct, and complete to the best of my knowledge. Name of Applicant Signature of Applicant Sworn to and subscribed before me this the My commission expires Date of expiration day of Date of Birth Position in Business Entity , 20 . Signature of notary or other person qualified by law to administer oaths OATH OF APPLICANT I certify as required by NCGS 18B-902(a) and (c) that this application and all attachments are true, correct, and complete to the best of my knowledge. Name of Applicant Signature of Applicant Sworn to and subscribed before me this the My commission expires Date of expiration day of Date of Birth Position in Business Entity , 20 . Signature of notary or other person qualified by law to administer oaths OATH OF APPLICANT I certify as required by NCGS 18B-902(a) and (c) that this application and all attachments are true, correct, and complete to the best of my knowledge. Name of Applicant Signature of Applicant Sworn to and subscribed before me this the My commission expires Date of expiration day of Date of Birth Position in Business Entity , 20 . Signature of notary or other person qualified by law to administer oaths NC ABC COMMISSION 4307 MAIL SERVICE CENTER RALEIGH NC 27699-4307 NC ABC COMMISSION 400 EAST TRYON ROAD RALEIGH NC 27610 Wine shipper Permit Application - Rev 11/2010 American LegalNet, Inc. www.FormsWorkFlow.com