Application For Alcoholic Beverage Direct Shipping License Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Application For Alcoholic Beverage Direct Shipping License Form. This is a North Dakota form and can be use in Office Of State Tax Commissioner Statewide.
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Tags: Application For Alcoholic Beverage Direct Shipping License, 59458, North Dakota Statewide, Office Of State Tax Commissioner
North Dakota Office of State Tax Commissioner
Application For Alcoholic Beverage
Direct Shipping License
New
For Year
ND License Number
Renewal
Legal Name
FEIN
DBA (if applicable)
Federal Basic Permit Number
Physical Address
City
State
Zip Code
Mailing Address
City
State
Zip Code
Telephone Number
Contact Person
Email Address
Any Information Changed From Previous Application
License Fee: $50.00
Type of Business:
Sole Proprietorship
Partnership
LLP
Corporation
LLC
1. The state of domicile for this business is
Yes
2. Is the business currently a licensed alcoholic beverage manufacturer?
License No.
, and Expiration Date
,
If Yes, enter State
of the license.
Yes
3. Is the business currently a licensed alcoholic beverage retailer?
License No.
No
, and Expiration Date
No
,
If Yes, enter State
of the license.
Agreement to Electronically File
The Tax Commissioner agrees to authorize the above named company to electronically file the tax reports and schedules as
required under North Dakota Century Code chs. 5-01 and 5-03. The signature of the company affixed to this application
shall be deemed to appear on such electronically filed reports and schedules, as if actually so appearing. All reports and
schedules filed electronically pursuant to this agreement are deemed by the company to be truthful, accurate and complete
statements made under penalty of perjury, and shall be in form compatible with the Tax Commissioner's equipment, software,
and facilities. Any electronic filing not in conformity with the requirements specified herein shall be deemed a failure to file
such reports and schedules and company shall be subject to all applicable penalties prescribed by law.
I declare under the penalties of North Dakota Century Code ยง 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
Please send application and license fee to:
Office of State Tax Commissioner
Alcohol Tax Section
600 E. Boulevard Ave. Dept. 127
Bismarck, ND 58505-0599
Phone: (701) 328-2702
Title
Date
For Tax
Department
Use Only
59458
Rev. 10/10
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