NORTH CAROLINA ALCOHOLIC BEVERAGE CONTROL COMMISSION 4307 Mail Service Center Raleigh, NC 27699-4307 Approved Rejected By Date Expires Wine Special Order I hereby make application to the North Carolina Alcoholic Beverage Control Commission for a Wine Special Order Permit as the following: NC Resident Retail Permittee All applicants complete the following: Individual's Full Name: (Please print) First (no abbreviations) Middle Last State Resident Address: Street City Zip Code Daytime Telephone #: ( ) Fax #: ( ) To be completed by the NC wholesaler/importer: Name of Importer/ Wholesaler: Address: NC Permit #: Manager: Printed name Signature Phone #: ( ) To be completed by the retail permittee: Name of Retail Permittee: Address: NC Permit #: Manager: Printed Name Signature Phone #: ( ) List the products that will be purchased: Brand Name and Type # Bottles Size Continued American LegalNet, Inc. www.FormsWorkFlow.com Brand Name and Type Quantity Size I CERTIFY UNDER OATH OR AFFIRMATION THAT: - I understand that the wine may not be sold unless I am a bonafied retail permittee holding on premise ABC permits. - I understand that I can only engage in activities authorized by the N.C. ABC Laws for the permit issued. - I understand as a holder of an on premise wine permit, if applicable, that the products and labels must conform to the standards of identity and labeling requirements for wine set forth in Subchapter 2T, Section.0400. - I understand that this permit only applies to products that are not presently approved for sale in North Carolina. - I understand that I may only purchase or transport up to 20 liters of unfortified wine and 8 liters of fortified wine. - I understand that I must obtain a Purchase-transport permit in order to purchase and transport over 50 liters of unfortified wine and over 8 liters of fortified wine not to exceed 100 liters of unfortified nor 40 liters of fortified wine. Signature of Individual Filing Application 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 FORWARD THIS APPLICATION TO: North Carolina Alcoholic Beverage Control Commission 4307 MAIL SERVICE CENTER RALEIGH, NC 27699-04307 Location: 400 East Tryon Road, Raleigh, NC 27610 Wine Special Order - Rev 11/2010 American LegalNet, Inc. www.FormsWorkFlow.com