OREGON LIQUOR CONTROL COMMISSION ENDORSEMENT TO RECEIVE WINE AND CIDER SHIPMENTS APPLICATION Licensee name: ___________________________________ Trade Name: ___________________________________ Business Address: ___________________________________ City/Zip code: License type: ______________ (Full On-Premises, Limited On-Premises, Off Premises, Brewery Public House) ___________________________________ Mailing Address: Phone: __________________ ___________________________________ City/State/Zip code:___________________________________ I am applying for the privilege to receive shipments of wine or cider from Wine Self Distribution permit holders. I understand that I may only accept shipments at the licensed location specified above and only from manufacturers who hold a Wine Self Distribution Permit. I understand that I must keep records of all deliveries I receive from Wine Self Distributor permit holders. I understand that I must keep these records for 2 years. I understand that I must submit monthly reports of the deliveries that I receive from permit holders on forms supplied by the Commission. The monthly reporting form will be mailed to you with your approval letter. The applicant or an authorized corporate officer or a member of a limited partnership or a Limited Liability Company must sign this application. Applicant Signature: ___________________________________ Date: ____________ Applicant Printed Name: ___________________________________ OLCC USE ONLY: Application is: Denied Approved by: ________________ Date: _____________ Reason for Denial: _______________________ Premises number: _____________ copy to Financial Services Oregon Liquor Control Commission 9079 SE McLoughlin Blvd. Portland, OR 97222-7355 • PO Box 22297 Milwaukie, OR 97269-2297 503-872-5123 • www.olcc.state.or.us 06/08 American LegalNet, Inc. www.FormsWorkflow.com