APPLICATION FOR ALCOHOLIC BEVERAGE MANUFACTURING LICENSE OFFICE OF NORTH DAKOTA STATE TAX COMMISSIONER SFN 59457 (10-10) For Year North Dakota License Number (renewals only) Federal Employer Identification Number Federal Basic Permit Number/Brewer's Notice New Legal Name DBA (if applicable) Physical Address Mailing Address Telephone Number Change of Any Information From Previous Application Type of Business Renewal City City Contact Person Email Address State State ZIP Code ZIP Code Sole Proprietorship Partnership Corporation Limited Liability Corporation Annual Fees: First year applicants are eligible for prorated fees based on the following table: April - June 30 Domestic Distillery ($100.00) . . . . . . . . . . . . . Domestic Winery ($100.00) . . . . . . . . . . . . . . Microbrew Pub ($500.00) . . . . . . . . . . . . . . . . North Dakota Manufacturing ($500.00) . . . . . . Winery Distillery Brewery $100.00 $100.00 $375.00 $375.00 July 1 - December 31 $100.00 $100.00 $250.00 $250.00 1. 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.) Yes No If yes, list establishments 2. Have you ever had any type of license suspended or revoked in North Dakota or in any other state? . . . . Yes No If yes, list where and when 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 to: Office of State Tax Commissioner Alcohol Tax 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