DATE 1.Name of Business 3.Premises (Physical) Address 2. Primary Business Telephone Number( ) - EXT 4.First Name, Middle Name, Last Name 8 .Your Email Address 5.Have you ever been known by ANY other name? Yes No 9. Your Primary Personal Telephone Number 10.Your Place of Birth 11.Your Birth Date 12.Your Social Security No. 6.Your Legal Residence Your Ge Check if the same as: Item 3 Item 6 1.Your Position or Title ith the Business nSection I. MALE 7.Your Work Address American LegalNet, Inc. www.FormsWorkFlow.com If the answer to any question in this section is 223,224 please provide full details in the area provided, the additional space on the last page, or on a separate sheet, taking care to number the responses to correspond with the question. Convictions, arrests, or charges for minor traffic violations need not be reported. .Have you ever been any violation of any FEDERAL or STATE lawroducts regulated by Chapter 51 (distilled spirits, wine, and beer) or 52 (tobacco products, processed tobacco, andcigarette papers and tubes) of the Internal Revenue Code or the Federal Alcohol Administration No 1.Have you ever been a FELONY violation of any other FEDERAL or Yes No Have you been a MISDEMEANOR violation of any other FEDERALlaw within the last ten (10) years? Yes .Have you ever been of any FELONY or MISDEMEANOR under FEDERAL or STATE law? Yes No .Have you ever compromised or settled, by payment (including fines), stipulated suspension, surrender of permit,any violation of FEDERAL law relating toproducts regulated by Chapter 51 (distilled spirits, wine, and beer) or 52 (tobaccoproducts, processed tobacco, and cigarette papers and tubes) of the Internal Revenue Code or any violation of the conditions ofa permit or registration issued to you under the Federal Alcohol Administration Act or the Internal Revenue Code? Yes No .Has disapproval ever been given to any application or notice of intention to distill, produce, brew, manufacture,rectify or blend, bottle, distribute, sell, or importproducts regulated by Chapter 51 (distilled spirits, wine, and beer) or 52(tobacco products, processed tobacco, and cigarette papers and tubes) of the Internal Revenue Code or the Federal AlcoholAdministration Act filed by you or any firm or corporation of which you were proprietor or a partner, officer, director, principalstockholder, or responsible employee? Yes .If your answer is 223,224 provide the name under which the application was filed and the reason(s) for No No American LegalNet, Inc. www.FormsWorkFlow.com individualinconnection withith a FEDERALpermit or approval to distill, produce, brew, manufacture, use, store, rectify or blend, bottle,distribute, sell, deal in, or importproducts regulated by Chapter 51 (distilled spirits, wine, and beer) or 52 (tobaccoproducts, processed tobacco, and cigarette papers and tubes) of the Internal Revenue Code or the Federal AlcoholAdministration Act?Yes Name and address under which thepermit/approvalwas issued. 2.Your Investments in the Business Listed in Section I. 2a. Have you invested any funds in the business to dateIf yes, please list the amount and the source of the funds, including the name and address of thelocationwhere the funds were held and the type of account and account number, if applicable.Savings / CheckingAccount Amount (in U.S. Dollars): Name and Address of Institution: Account Number: Personal or Business (please circle) Loan from a Lending Institution Amount (in USD): Personal or Business (please circle) Loan from an Individual Amount (in USD): Credit cards Amount (in USD): Gift (please specify the source and your relationship) Amount (in USD): Source(s): Relationship(s): Other American LegalNet, Inc. www.FormsWorkFlow.com .Please use this space to provide additional information or explanation, if necessary, taking care to number theresponses to correspond to the question (continue on separate sheet, if needed). Under the penalties of perjury, I declare that this statement, including the documents submitted in support thereof, has been examined by me and, to the best of my knowledge and belief, is true, correct, and complete. .Applicant Signature .Date American LegalNet, Inc. www.FormsWorkFlow.com The following information is provided pursuant to Section 3 and 7(b) of the Privacy Act of 1974 (5 U.S.C. 552a(e)(3)): To enable TTB to determine the eligibility, suitability, and/or qualifications of an applicant whoproposes to engage in a business regulated by TTB. The information will be used by TTB to make the determinations set forth in paragraph 2. In Failure to provide complete information mayprevent TTB from making an informed judgment regarding the eligibility, suitability, and/or qualification of theapplicant. This may result in either a delay in the approval of an application or its disapproval. Disclosure of the individual social security number is voluntary. This request is in accordance with the Paperwork Reduction Act of 1995. The information collection is used by TTB to determine if an applicant is eligible to receive a TTB permit or TTB approval to operate a regulated alcohol or tobacco business . The information is mandatory (26 U.S.C. 5171(d), 5181, 5271(b), 5356, 5401(a), 5502(b), 5511(3), and 5712; 27 U.S.C. 204). The estimated average burden associated with this collection of information is per respondent, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be addressed to the Reports Management Officer, Regulations and Rulings Division, Alcohol and Tobacco Tax and Trade Bureau, 1310 G Street, NW, Washington, DC 20. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current, valid OMB control number. American LegalNet, Inc. www.FormsWorkFlow.com