North Dakota Office of State Tax Commissioner Application For A Domestic Distillery Special Events Permit ND License Number Legal Name DBA (if applicable) Physical Address Mailing Address Telephone Number Contact Person City City FAX Number Email Address FEIN Federal Basic Permit Number State State Zip Code Zip Code There is no fee for this permit. 1. Name of special event: 2. Type of event (for example, trade show, convention, festival): 3. Number of dates requested: 4. Dates domestic distillery plans to participate: 5. Location of the special event: Name of facility Address City State Zip Code I declare under the penalties of North Dakota Century Code § 12.1-11-02, which provides for a Class A misdemeanor for making a false statement in a governmental matter, that this application has been examined by me and to the best of my knowledge and belief is complete, correct, and true. Name of Owner or Authorized Officer (print or type) Signature of Owner or Authorized Officer Title Date Please send application to: Office of State Tax Commissioner Alcohol Tax Section 600 E. Boulevard Ave. Dept. 127 Bismarck, ND 58505-0599 Phone: 701.328.3158 24152 Rev. 10/10 American LegalNet, Inc. www.FormsWorkFlow.com