APPLICATION FOR WHOLESALE BEER OR LIQUOR LICENSE Tax Type 96 OFFICE OF STATE TAX COMMISSIONER SFN 22921 (11-05) FOR TAX DEPARTMENT USE ONLY Ë Wholesale Beer License Fee $200 APPLYING FOR (Check only ONE): Separate application required for each license. Business Name (Corporate or Legal) Ë Wholesale Liquor License Fee $1,000 FEIN License Number Federal Wholesale Basic Permit Number (For Alcohol Beverage Wholesale) dba Business Names (if any) Phone # Mailing Address City State Type of Business Ë Sole Proprietorship Fax # Zip Code County Ë Partnership Ë Corporation All Applicants: 1. Do you have any financial interest in any retail alcoholic beverage establishment? (If corporation, include all officers, directors and stockholders; if partnership, include all partners.) If yes, list establishments below....................................................................................Ë Yes ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ 2. Does any alcoholic beverage manufacturer or alcoholic beverage retailer have any financial interest in this wholesale business? If yes, list below .............................................................................................................................................................................................Ë Yes ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ 3. Do you have a warehouse or office in North Dakota or a state which has reciprocity with North Dakota regarding this provision, which contains a complete record of all your North Dakota transactions? If yes, list all locations below, including addresses and managers .................................................................................................................................................................Ë Yes Location ______________________________________ ______________________________________ Address ______________________________________ ______________________________________ Ë No Ë No Ë No Manager ______________________________________ ______________________________________ Individuals and Partnership: 1. If partnership, list all partners: ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ 2. Are all partners citizens of the United States and residents of North Dakota? ..............................................................................................Ë Yes Ë No 3. Have any partners ever been convicted of a felony? If yes, list name and details below .............................................................................Ë Yes __________________________________________________________________________________________________________ Ë No Corporations: 1. Are you properly registered with the North Dakota Secretary of State? .......................................................................................................Ë Yes Ë No 2. Is your manager a resident of the State of North Dakota? .............................................................................................................................Ë Yes Ë No 3. Has your manager ever been convicted of a felony? If yes, explain below..................................................................................................Ë Yes __________________________________________________________________________________________________________ Ë No 4. Are all officers, directors, and stockholders citizens of the United States? List those persons below .........................................................Ë Yes __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Ë No 5. Have any officers, directors, or stockholders ever been convicted of a felony? If yes, list name and details below ...................................Ë Yes Ë No __________________________________________________________________________________________________________ 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. ____________________________________________________________ Name of Owner or Authorized Officer (print or type) ____________________________________________________________ Signature of Owner or Authorized Officer DO NOT WRITE IN THIS SPACE 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 ________________________________ ___________________________ Title Date Phone: (701) 328-2702 Fax: (701) 328-1283 American LegalNet, Inc. www.FormsWorkflow.com