APPLICATION FOR ALCOHOLIC BEVERAGE DIRECT SHIPPING LICENSE OFFICE OF NORTH DAKOTA STATE TAX COMMISSIONER SFN 60429 (7-13) For Calendar Year ND License Number (renewals only) Federal Employee Identification Number Fed. Basic Permit or Brewer's Notice # New License Legal Name DBA (if applicable) Physical Address Mailing Address Telephone Number Renewal City City Contact Person Email Address State State ZIP Code ZIP Code Change of Any Information From Previous Application Annual Fee: $50.00 State Domicile for this Business Liquor (Wine) Beer Make check payable to Office of State Tax Commisisoner Is the business currently a licensed alcoholic beverage retailer? No Yes If yes, enter information below and attach a copy of license State License Number Attached Expiration Date Is the business currently a licensed alcoholic beverage manufacturer? No Yes If yes, enter information below and attach a copy of license State License Number Attached Expiration Date Manufacturers must attach a copy of their Federal Basic Permit or Brewer's Notice. Attached 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 Title Date Please send application and license fee to: Office of State Tax Commissioner Sales and Special Taxes Compliance Section 600 E. Boulevard Ave. Dept. 127 Bismarck, ND 58505-0599 Phone: 701.328.2702 For Tax Department Use Only American LegalNet, Inc. www.FormsWorkFlow.com