APPLICATION FOR WHOLESALE BEER OR LIQUOR LICENSE SFN 59455 (10-10) OFFICE OF NORTH DAKOTA STATE TAX COMMISSIONER For Year New Legal Name DBA (if applicable) Physical Address Mailing Address Telephone Number Any Information Changed From Previous Application Type of Business Renewal North Dakota License Number (renewals only) Federal Employer Identification Number Federal Basic Permit Number/Brewer's Notice City City Contact Person Email Address State State ZIP Code ZIP Code Sole Proprietorship Partnership Corporation Annual Fees: First year applicants are eligible for prorated fees based on the following table: April - June 30 Wholesale Beer License ($200.00) . . . . . . . . . . . . . Wholesale Liquor License ($1,000.00) . . . . . . . . . . $150.00 $750.00 July 1 - December 31 $100.00 $500.00 All applicants 1. Do you have any financial interest in any retail alcoholic beverage establishment? (If corporation, include all officers, directors, and stockholders; if a partnership, include all partners.) If yes, list establishments below . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 2. Does any alcoholic beverage manufacturer or alcoholic beverage retailer have any financial interest in this wholesale business? If yes, list below . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 3. Do you have a warehouse and office in North Dakota (or for beer, in a state which has reciprocity with North Dakota regarding this provision) which contains a complete record of all of your North Dakota transactions? If yes, list all locations below, including addresses and managers . . . . . . . . Yes Street Address, City, State & ZIP Code Manager No For Tax Department Use Only American LegalNet, Inc. www.FormsWorkFlow.com SFN 59455 (10-10) Page 2 Individuals and Partnership 4. If partnership, list partners: Yes No 5. Are all partners citizens of the United States and residents of North Dakota? . . . . . . . . . . . . . . . Yes No No 6. Have any partners ever been convicted of a felony? If yes, list name and explain below . . . . . . . Yes Corporations 7. Are you properly registered with the North Dakota Secretary of State? . . . . . . . . . . . . . . . . . . . 8. Is your manager a resident of the State of North Dakota . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. Has your manager ever been convicted of a felony? If yes, list name and explain below . . . . . . . Yes Yes Yes No No No 10. Are all officers, directors, and stockholders citizens of the United States? List those persons below . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 11. Have any officers, directors, or stockholders ever been convicted of a felony? If yes, list name and explain below . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 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