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 § 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 American LegalNet, Inc. www.FormsWorkFlow.com