REMARKS: REVIEWER ACTION:Taxing District:Permit Number:Type of Transaction: Bus. Type Data Entry Initials:ClassReceipt # Proc. Fee Paid: YES NOBCI Fee Amount Paid: $ Class Fee Paid: YES NO American LegalNet, Inc. www.FormsWorkFlow.com a) Import from outside the United States beer, wine or mixed beverages? b) Manufacture, brew, or produce, beer, wine or mixed beverages? $$NOTE: ALL DOCUMENTS WILL BECOME PART OF THE PERMIT FILE AND NOT RETURNEDPAGE 2 'S%$ (Title)(Please Print Name)(Date)(Address)(City) (State) (Zip Code) (Area Code & Telephone Number) THE FOLLOWING MUST BE SIGNED BY THE APPLICANT:I certify that the information provided on this form is true, correct, and complete to the best of my knowledge and belief, and that I am at least twenty-one (21) years of age.(Signature of Individual, Partner, Officer, Managing Member, or 5% or more Stockholder or Member) American LegalNet, Inc. www.FormsWorkFlow.com