OREGON LIQUOR CONTROL COMMISSION RECORD OF MALT BEVERAGE, WINE, AND CIDER DELIVERY TO A RESIDENT OF OREGON This form may be used by OLCC approved Oregon licensees and Direct Shipper Permit holders to record deliveries of malt beverage, wine, or cider to Oregon residents. Remember that delivery records must be retained by the Direct Shipper Permit holder or licensee for a minimum of 18 months from the date of delivery of the alcohol to the resident. Direct Shipper Permit holders and Off-Premises Sales licensees see OAR 845-005-0417 and 845-006-0392 for the qualifications and requirements to make deliveries of wine or cider to residents of Oregon. Off-Premises Sales and Brewery-Public House licensees see OAR 845-005-0420 and 845-006-0396 for the qualifications and requirements to make deliveries of malt beverage to residents of Oregon. The person DELIVERING the alcohol must complete this section: Business Trade name: ____________________________________________________________________ (Name of Business Delivering the Alcohol) Date Delivered:______/______/_______ (MM/DD/YYYY) Time Delivered: ___________ am/pm Type of Alcohol Delivered ________________________ Amount of Alcohol Delivered ________________ (Wine, Cider, Malt Bev.) Delivered to: ___________________________________________ _______________________________ ___ Printed name, taken from his/her photo identification, of person receiving the alcohol ______________________________________________________________________ _____ __ Street Address City I verify that the person receiving the alcohol is not visibly intoxicated, that I inspected government-issued photo identification of the person receiving the alcohol, and that the person is at least 21 years of age. _______________________________________ Signature of person making delivery ____________________ ____________________ Printed name of person making delivery The person RECEIVING the alcohol must sign here: Signature: ______________________________________________________________________________ 1-800-452-6522 www.oregon.gov/olcc (07/2008) American LegalNet, Inc. www.FormsWorkflow.com