Application For Domestic Winery Or Alcoholic Beverage Manufacturing License Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Application For Domestic Winery Or Alcoholic Beverage Manufacturing License Form. This is a North Dakota form and can be use in Office Of State Tax Commissioner Statewide.
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Tags: Application For Domestic Winery Or Alcoholic Beverage Manufacturing License, SFN 22935, North Dakota Statewide, Office Of State Tax Commissioner
North Dakota Office of State Tax Commissioner
Application For Domestic Winery or
Alcoholic Beverage Manufacturing License
For Year
New
ND License Number (renewals only)
Renewal
Legal Name
FEIN
DBA/Trade Name
Federal Basic Permit Number
Physical Address
City
State
Zip Code
Mailing Address
City
State
Zip Code
Telephone Number
Contact Person
Address Changed From Previous License Application
Type of Business:
Sole Proprietorship
Email Address
Partnership
Corporation
Annual Fees: Initial Filers are eligible for prorated fees based on the following table:
April - June 30
July 1 - December 31
Domestic Winery ($100.00) . . . . . . . . . . . . . .
$100.00
$100.00
Microbrew Pub ($500.00) . . . . . . . . . . . . . . .
$375.00
$250.00
ND Manufacturing ($500.00) . . . . . . . . . . . .
$375.00
$250.00
Winery
Distillery
Brewery
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
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? . . . . . . . . . . . . . .
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 ยง 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
22935
Rev. 4/07
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