TERRITORY DESIGNATION FORMTO BE COMPLETED BY THE SUPPLIER COMPLETE ONE FORM FOR EACH WHOLESALE DISTRIBUTORSTATEOHIOType of Filing:Does Distributor have Statewide Distribution? If NO, please indicate the assigned counties below: List Brands to be Sold by this Distributor:COUNTYPARTCOUNTYPARTCOUNTYALLPARTCOUNTYALLAdamsFairfieldLickingPortageAllenFayetteLoganPrebleAshlandFranklinLorainPutnamAshtabulaFultonLucasRichlandAthensGalliaMadisonRossAuglaizeGeaugaMahoningSanduskyBelmontGreeneMarionSciotoBrownGuernseyMedinaSenecaButlerHamiltonMeigsShelbyCarrollHancockMercerStarkChampaignHardinMiamiSummitClarkHarrisonMonroeTrumbullClermontHenryMontgomeryTuscarawasClintonHighlandMorganUnionColumbianaHockingMorrowVan WertCoshoctonHolmesMuskingumVintonCrawfordHuronNobleWarrenCuyahogaJacksonOttawaWashingtonDarkeJeffersonPauldingWayneDefianceKnoxPerryWilliamsDelawareLakePickawayWoodErieLawrence PikeWyandot , hereby state the above information is true and correct. (Print Name)(Signature)(Title) (Company)(Effective Date) DLC 1539 Rev. (4/2019) An Equal Opportunity Employer and Service Provider TTY Users Dial ORS 1-800-750-0750 Ohio Out of State Supplier Permit #: Supplier Name: Company Address: City: State:Zip:Telephone No. Dba Name:Wholesale Distributor Name:Street Address:City:Zip: NEW CANCELLED AMENDED TERRITORIES FOR DISTRIBUTOR NO YES ALLALLPART I, If you check "part" of a county, it will be necessary for you to identify that portion of the county. Please indicate that information on a separate page and attach to this form. E-mail Address: 6606 TUSSING ROAD - P.O. BOX 4005REYNOLDSBURG, OH 43068-9005 614-644-2411 American LegalNet, Inc. www.FormsWorkFlow.com TERRITORY DESIGNATION FORM Please complete one form for each Ohio wholesale distributor designated to distribute your products. If you are an Ohio manufacturer holding an A-1, A1c, B-2a, or A-4 you may sell directly to Ohio retail permit holders and do not need to submit this form unless you use an Ohio Wholesale Distributor for sales to retail permit holders. Ohio has exclusive sales territories for wholesale distributors of beer, wine and mixed beverages. These provisions are found within the following Ohio laws and Ohio Liquor Commission Rules: Ohio Revised Code 4301.241 -Notwithstanding section 4303.06 of the Revised Code, each manufacturer and supplier of beer shall assign to each of the manufacturer222s or supplier222s B-1 distributors a sales area or territory within which each B-1 permit holder shall be the distributor of the brand or brands of the manufacturer or supplier, provided that, if the manufacturer or supplier manufactures or supplies more than one brand of beer, the manufacturer or supplier may assign sales areas or territories to additional B-1 distributors for the distribution and sale of the additional brand or brands, so long as not more than one distributor distributes the same brand or brands within the same sales area or territory. No B-1 distributor shall distribute a specific brand of beer in any area or territory other than the area or territory assigned to the distributor.Ohio Administrative Code 4301:1-1-43 -(D)(3) The division shall not grant consent to import for, or approve the registration of, any brand of beer or intoxicating liquor until the supplier files the appropriate forms with the division. Such filing shall consist of the filing of the applications for supplier and label registration and territory designation forms with the division by the supplier. In addition, the division of liquor control shall not grant consent to import or approve the registration of any brand of beer or intoxicating liquor to any party if consent to import or registration for such brand has already been granted to any other party and is currently in effect. The division shall not grant consent to import, or approve the registration or accept a territory designation form if it would allow any A or B permit holder to distribute the same brand or brands of beer or intoxicating liquor within the same sales area or territory assigned to another A or B permit holder by the manufacturer or the supplier authorized by the manufacturer to import such products in Ohio.(a) Upon the appointment or change of appointment of the supplier by a manufacturer, the supplier shall immediately provide the division of liquor control with evidence of written authorization from the manufacturer that it represents that brand or those brands of beer or intoxicating liquor in Ohio. (b) Failure on the part of any supplier to provide the division with evidence of the manufacturer222s authorization, or to discontinue shipping upon termination of any authorization, shall be cause for the division to cite the supplier before the commission for suspension or revocation of that supplier222s registration in Ohio. (4) No wholesale distributor shall handle or deliver any brand of alcoholic beverage that has been introduced for sale or otherwise acquired for sale in the state of Ohio after November 1, 1985, in any sales area or territory that has not been assigned by the manufacturer or the supplier authorized by such manufacturer to import the brand or brands into Ohio. The manufacturer or supplier shall file with the division a description of the designated sales area or territory, with a copy sent to the affected wholesale distributor. INSTRUCTIONS FOR COMPLETING THE TERRITORY DESIGNATION FORM Complete the Designation form in its entirety paying particular attention to the following items: Supplier Information 1. Supplier Name 226 use the same name as contained on your Ohio Supplier license certificate. If you are simultaneously applying for a suppliers license use the same name as on your supplier application. 2. Supplier Permit number 226 This number, also known as 223registration Number224 is found on your Ohio Supplier license certificate. 3. Supplier DBA 226 List any additional names the suppler could be associated with. 4. Company Address 226 This address must be the same as listed on your Ohio Supplier license certificate. Ohio Wholesale Distributor Information 1. Ohio Wholesale Distributor Name 226 It is very important that you use the same name as is registered with the Ohio Division of Liquor Control. Please check with your distributor to obtain the name their license is issued under. You may also view on our web site a list of Ohio222s wholesale distributors at: http://www.com.ohio.gov/liqr/rpts/Activebtypepermits.txt 2. Ohio Wholesale Distributor DBA 226 if the Ohio Wholesale Distributor has notified you of their DBA, please list it here. 3. Ohio Wholesale Distributor address, City, Zip 226 this must match the information contained on their Ohio permit certificate. Type of Filing 1. Check the appropriate box based upon the following criteria: 225New 226 If this is the first time you have assigned a territory for the brand(s) listed or you are assigning a previously appointed territory to a new Ohio Wholesale Distributor. 225Amended 226 If you are changing a territory i.e. adding to or deleting a portion of, an assigned territory for a Ohio Wholesale Distributor. Assigning Territory 1. If the Ohio Wholesale Distributor has statewide distribution, check the 223YES224 box. If there is more than one Ohio Wholesale Distributor used for distribution, check the 223NO224 box and indicate which counties the distributor is assigned. 2. If the distributor has the entire county, place a mark in the 223ALL224 box for that county. If the distributor has a portion of the county, place a mark in the 223PART224 box for that county and indicate which portion of that county on a separate page and attach to this form. 3. Complete one territory form for each Ohio Wholesale Distributor. 4. Each brand you have registered for sale in Ohio must have a corresponding territory designation. Please list the brands in alphabetical order. American LegalNet, Inc. www.FormsWorkFlow.com