APPLICATION FOR SOLICITOR REGISTRATION (See Instructions on Page 2)6606 TUSSING ROAD - P.O. BOX 4005REYNOLDSBURG, OH 43068-9005 614-644-2411SECTION I SALES PERSON OR AGENT REGISTRATION INFORMATIONPlease indicate your current status under which you are a salesperson or agent.SECTION II SALES PERSON/ AGENT PERSONAL INFORMATION 1. Is applicant an employee of or have any financial interest, directly or indirectly, by stock ownership, interlocking directors in a 2. Has applicant ever been denied, had revoked, or had a renewal rejected for any type of liquor permit in this, or any other state? 3. Has applicant ever been convicted of a felony or misdemeanor, including any alcohol-related offenses? If YES, a full explanation and copy of certified journal entry, sentence or disposition MUST be attached. SECTION III PLEASE COMPLETE THIS SECTION INDICATING THE OHIO MANUFACTURER, OHIO WHOLESALE DISTRIBUTOR, FOR DIVISION USE ONLYID# DATE ISSUED CHECK# AMOUNT$ DLC 1504 FOR TTY USERS DIAL 1-800 -750-0750 EOE/ADA SERVICE PROVIDER REVISED 10/28/2014 I am a salesperson or agent employed by an Ohio manufacturer, Ohio wholesale distributor, or a supplier of beer, wine, mixed beverages or spirituous liquor. I am a salesperson or agent who is self employed and represents the products of an Ohio manufacturer, Ohio wholesale distributor, supplier or broker of beer, wine, mixed beverages or spirituous liquor. I am a salesperson, agent, or trade marketing professional who is employed by a trade marketing company or broker that represents the products of an Ohio manufacturer, Ohio wholesale distributor, or supplier of beer, wine, mixed beverages or spirituous liquor.NAME:BIRTH DATE:RESIDENCE ADDRESS:CITY:ZIP CODE:STATE: NO YES YES NO If YES, please explain? NO YES Superintendent Approval/Denial:(Signature)(Date) ApprovedDenied If YES, please list the name of the retail permit holder and in what capacity you are employed on the line provided: SUPPLIER, BROKER OR TRADE MARKETING COMPANY FOR WHOM YOU ARE A SALESPERSON OR AGENT.$50.00 FEE - MADE PAYABLE TO THE OHIO DIVISION OF LIQUOR CONTROL NAME OF COMPANY:ADDRESS OF COMPANY:CITY:ZIP CODE:STATE:PHONE NUMBER: The above referenced company holds an Ohio permit, Ohio supplier registration, Ohio Spirits Vendor registration, or is a Broker with the Division of Liquor Control. Please indicate permit or registration number SECTION IV NOTARIZED SIGNATURE OF APPLICANT *Attach to this application a letter of confirmation from your employer or the company you represent, stating that you are currently employed by or a salesperson or agent of such company and that you are authorized to sell and represent their products. I, (Please Print Name) being first duly sworn, according to law, depose and say that the statementsSworn to before me and subscribed in my presence this day of , 20 .(Notary Public)(Notary Expiration)and answers made in the foregoing application are true.(Signature of Applicant) (Title)(Date) BUSINESS PHONE NUMBER:RESIDENCE PHONE NUMBER : Please check the appropriate box regarding the company for whom you are a salesperson or agent: The above referenced company does not hold an Ohio permit, Ohio supplier registration or Ohio Spirits Vendor registration with the Division of Liquor Control and operates as a broker or trade marketing company for an Ohio manufacturer, Ohio wholesale distributor or supplier. EMAIL ADDRESS:EMAIL ADDRESS: 1. 2. corporation, or otherwise, in the establishment, maintenance, or promotion of the business of an Ohio retail permit holder? American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR SOLICITOR REGISTRATION < A "Trade marketing professional" is defined as an individual who is an employee of, or is under contract with, a trade marketing company and who has successfully completed a training program on subjects such as the illegal serving of alcohol to persons under 21 years of age. < A "Trade marketing company" is defined as a company that solicits the purchase of beer and intoxicating liquor and educates the public about beer and intoxicating liquor. < A 223Broker" is defined as a company that solicits sales of alcoholic beverages on behalf of a manufacturer or supplier, but generally does not take possession of the beverages. < A "Solicitor" is defined as an individual who solicits sales of alcoholic beverages on behalf of a manufacturer, supplier, wholesale distributor, or broker, and generally does not take possession of the beverages. Any individual acting as an agent, solicitor, trade marketing professional or salesperson for any manufacturer, supplier, wholesale distributor, trade marketing company or broker of beer, wine, mixed beverages, or spirituous liquor which products are to be sold or produced in the state of Ohio, who is licensed or otherwise authorized to do business in Ohio shall be required to register with the division every two years upon the individual's date of registration pursuant to section 4303.25 of the Revised Code. This registration is also required for all individuals soliciting the Ohio Division of Liquor Control and Ohio permit holders. 1. Please include a $50.00 registration fee made payable to the Ohio Division of Liquor Control. 2. Be sure to have the application notarized. 3. Please direct any questions to (614) 644-2411. Section I Complete all personal information for the individual applying for the solicitor registration and indicate if the applicant is employed by an Ohio permit holder (i.e., manufacturer, supplier or wholesale distributor), self employed or an employee of a trade marketing company, or a broker that represents alcoholic beverages. Section II Answer all personal information questions and supply additional information if so required. Section III Complete this section listing the company you are employed by or if self employed, the company you act as an agent for. Check box #1 if the company holds an Ohio permit, Ohio supplier registration or Ohio spirits vendor registration ("VR") with the Division of Liquor Control. Indicate their permit, registration number or VR number. Check box #2 if the company does not have an Ohio permit, registration or VR number and the company solicits sales of alcoholic beverages on behalf of a manufacturer, supplier or wholesale distributor. In this case, the company would be considered a broker or a trade marketing company for an Ohio manufacturer, Ohio wholesale distributor or supplier. *Attach to the application a letter of confirmation from your employer or the company you represent, stating that you are currently employed by or a salesperson or agent of such company and that you are authorized to sell and represent their products. All trade marketing companies or brokers must have on file with the Division of Liquor Control a letter of authorization from the Ohio manufacturer, Ohio wholesale distributor, or supplier of beer, wine, mixed beverages or spirituous liquor that they represent.THE OHIO DEPARTMENT OF COMMERCE DIVISION OF LIQUOR CONTROL AN EOE/ADA SERVICE PROVIDER TTY USERS DIAL ORS 1-800-750-0750Page 2 American LegalNet, Inc. www.FormsWorkFlow.com