APPLICATION FOR ALCOHOLIC BEVERAGE MANUFACTURING LICENSE FOR DOMESTIC WINERY OR MICROBREW PUB OFFICE OF STATE TAX COMMISSIONER TAX TYPE 96 SFN 22907 (10-05) FOR TAX DEPARTMENT USE ONLY License Number Ë New License Ë License Renewal Name of Applicant (business, partnership, corporation) DBA or Trade Name FEIN Location of manufacturing business Mailing Address City County FAX # Telephone # Type of Business: Ë Sole Proprietorship Ë Partnership 1. Type of alcoholic beverage manufacturing: State E-Mail Address Ë Corporation Ë Domestic Winery Zip Code Ë LLC Ë Microbrew Pub Anticipated mfg. capacity ______________ 2. Do you have any financial interest in any wholesale or retail beer or liquor establishment? (If corporation, this includes all officers, directors, and stockholders; if a partnership, this includes all partners.) Ë Yes Ë No If yes, list establishments ______________________________________________________________________________________ Ë Yes 3. Have you ever had any type of license suspended or revoked in North Dakota or in any other state? Ë No If yes, list where and when ____________________________________________________________________________________ 4. List basic federal permit and other permit number and their effective dates Permit type _________________________________________ Permit # ______________________ Effective date _______________________ 5. Did you file an application for a retail license with the North Dakota Office of Attorney General? Ë Yes N.D.C.C. §§ 5-01-14 and 5-01-17 may require both a manufacturers license and a retail license. For retail license information contact: Office of Attorney General Licensing Division 600 E. Boulevard Ave. Bismarck, ND 58505-0040 Ë No Phone: (701) 328-2329 Fax: (701) 328-3535 6. North Dakota law provides that no foreign corporation or foreign limited liability company may conduct business in this state or obtain any license or permit required by this state until it has procured a certificate of authority from the secretary of state. North Dakota law also provides that no foreign limited partnership or foreign limited liability partnership may conduct business in the state until it has registered with the secretary of state. (Questions regarding certificates of authority and registrations should be directed to the North Dakota Secretary of State at (701) 328-4284.) List the state in which your company is organized ________________________ Enter the ID number assigned to your business by the North Dakota Secretary of State or attach a copy of the Certificate of Authority. ________________________________________________________________________________________________________________________ 7. You have the option to file your domestic winery tax returns annually or quarterly. Indicate your choice by checking one of the boxes below. Ë Annually (calendar year) Ë Quarterly First-time license fee - Domestic Winery = $100.00; Renewal fee = $100.00 per calendar year. First-time license fee - Microbrew Pub = $500.00 (reduced to $375.00 for effective dates between April 1 and June 30, and reduced to $250.00 for effective dates between July 1 and December 31). Renewal fee = $500.00 per calendar year. I, the undersigned, hereby apply for the above indicated license for the calendar year ending December 31, ________. I understand that any misstatement or concealment of fact in this application shall be grounds for revocation of the license. ____________________________________________________________ Signature of Applicant _______________________________ Title ___________________________ Date DO NOT WRITE IN THIS SPACE Please send application and license fee to: Office of State Tax Commissioner Alcohol Tax Section Phone: (701) 328-2702 600 E. Boulevard Ave., Dept. 127 Fax: (701) 328-1283 Bismarck, ND 58505-0599 American LegalNet, Inc. www.FormsWorkflow.com