PLCB-2236 4/02 I APPLICATION FOR DIRECT WINE SHIPPER COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD BUREAU OF LICENSING (SEE INSTRUCTIONS ON REVERSE) The undersigned hereby applies for a direct wine shipper license for the license period ending . 1. APPLICANT NAME (IF ANY) 2. ADDRESS OF BUSINESS (STREET, RURAL ROUTE, P.O. BOX NO.) (POST OFFICE) 3. INTERNET ADDRESS: (STATE) (ZIP) E-MAIL ADDRESS: http:www. RESOLUTION 4. FOR CORPORATIONS ONLY At a regular or special meeting held on 20 by the applicant, it was resolved that said application be filed with the Pennsylvania Liquor Control Board, and that and/or is/are hereby (NAME OF OFFICER/TITLE) (NAME OF OFFICER/TITLE) authorized to execute said application, and any other papers required by the Board. 5. Do you hold any other PLCB licenses or permits? Yes No If yes, list license identification number (LID) 6. Do you hold a license(s) to produce, supply, import, wholesale, distribute or retail wine in a state other than Pennsylvania? Yes No If yes, list the state(s) and the respective license identification, including name in which the license is held and assigned license number: If the name in which the license is issued is other than the applicant as listed above, provide a reason: 7. Has any license or permit issued by another state been revoked, cancelled or voided by that licensing authority? Yes No If yes, list the specific information, including the state: 8. Type of Business: Sole Proprietor Partnership Corporation Limited Liability Company 9. COMPLETE IN DETAIL - ATTACH SEPARATE SHEET, IF NECESSARY. NAME OF INDIVIDUAL APPLICANT, MEMBERS, PARTNERS OR OFFICERS & DIRECTORS TITLE HOME ADDRESS DATE AND PLACE OF BIRTH A. NAME B. NAME C. NAME D. NAME DO NOT WRITE BELOW THIS LINE ZIP _ _ _ _ _ - _ _ _ _ American LegalNet, Inc. www.FormsWorkflow.com Applicant agrees, if licensed, to comply with the attached Terms and Conditions. I swear or affirm under the penalties provided by 18 Pa. C.S. §4904 and 47 P.S. §403(h), that the foregoing answers and statements provided herein are true and complete to the best of my knowledge and belief. SIGNATURE TITLE NAME OF ATTORNEY REPRESENTING YOU IN THIS MATTER, IF ANY HOME ADDRESS PHONE ADDRESS ( SIGNATURE HOME ADDRESS ) TITLE PHONE ( BUSINESS PHONE NO. ( PHONE ) ( ) DATE SIGNED ) INSTRUCTIONS This application is to be filed to apply for a new direct wine shipper license. All separate sheets must include the applicant’s name and the business address. There is no fee. Tax Certification Statement (PLCB-1898) must be completed and submitted with the application. INFORMATION Do not submit any other document with this application packet. Should you be required to submit any documentation, you will be notified in writing. IF YOU REQUIRE ASSISTANCE IN COMPLETING THE APPLICATION PACKET, CALL THE LICENSING INFORMATION CENTER AT (717) 783-8250. SEND THE APPLICATION PACKET TO: PENNSYLVANIA LIQUOR CONTROL BOARD, BUREAU OF LICENSING, P.O. BOX 8940, HARRISBURG, PA 17105-8940. American LegalNet, Inc. www.FormsWorkflow.com