APPLICATION FOR ALCOHOLIC BEVERAGE SUPPLIER LICENSE OFFICE OF NORTH DAKOTA STATE TAX COMMISSIONER SFN 59454 (11-09) ND License Number Legal Name DBA/Trade Name Physical Address Mailing Address Telephone Number Contact Person City City FAX Number Email Address Federal Employer Identification Number Federal Basic Permit Number State State ZIP Code ZIP Code There are no fees for this license. Check the categories that apply to your business: Manufacturer Add type of license: Liquor/Wine Importer Beer Marketer Wholesaler 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 American LegalNet, Inc. www.FormsWorkFlow.com