plcb-1905 2/12 commonwealth of pennsylvania pennsylvania liquor control board application for malt or brewed beverage brand registration bureau of licensing (SEE INSTRUCTIONS PAGE 2 OF 2) The undersigned hereby applies for a brand registration as a  franchisee 1.  Name of applicant  manufacturer of the listed brands. official use only bc# 2. Trading as 3. Business (STREET, RURAL ROUTE, P.O. BOX NO.)            (POST OFFICE)           (STATE)        (ZIP) 4. THE FOLLOWING IS A COMPLETE LIST OF THE MALT OR BREWED BEVERAGES WHICH ARE TO BE SOLD IN THE COMMONWEALTH. A LABEL FOR EACH BRAND MUST BE ATTACHED. (ATTACH SEPARATE SHEET IF NECESSARY.) brand name 100 barrels or less brand name 100 barrels or less A. G. B. H. C. I. D. J. E. K. F. 5. for franchisees only name of manufacturer(s) of brand(s) listed in #4 business address A. B. C. D. DO NOT WRITE BELOW THIS LINE American LegalNet, Inc. www.FormsWorkFlow.com 6. LIST ALL PA IMPORTING DISTRIBUTORS WITH WHOM PRIMARY TERRITORIAL AGREEMENTS HAVE BEEN ESTABLISHED FOR EACH BRAND LISTED. ATTACH A COPY OF SUCH AGREEMENT FOR EACH ID. (ATTACH SEPARATE SHEET IF NECESSARY.) plcb importing distributor no. name and address of pa importing distributors A. ID – B. ID – C. ID – D. ID – E. ID – F. ID – G. ID – H. ID – I. ID – J. ID – K. ID – L. ID – M. ID – N. ID – O. ID – P. ID – The undersigned hereby agrees: A. To notify the Pennsylvania Liquor Control Board of any additions that may be made to the above list during the effective period of this registration and to pay any additional fee which may be required through such additions. B. That the applicant will comply at all times with and observe all the provisions of the laws of Pennsylvania relating to the manufacture, sale, possession or transportation of malt or brewed beverages and the regulations of the Board. I swear or affirm, subject to the penalties provided by 18 Pa. C.S. §4904, and 47 P.S. §4-436(j), that the foregoing answers and statements provided herein are true and complete to the best of my knowledge and belief. name of official title DEPARTMENT/OFFICE ADDRESS phone signature of person completing form title address (IF DIFFERENT FROM ABOVE) phone e-mail address DATE signed American LegalNet, Inc. www.FormsWorkFlow.com plcb-1905 2/12 commonwealth of pennsylvania pennsylvania liquor control board application for malt or brewed beverage brand registration BUREAU OF LICENSING page 2 of 2 INSTRUCTIONS This form is to be submitted to register brands of malt or brewed beverages to be sold in Pennsylvania. Fees and documents to be submitted include: 1. Application, PLCB-1905. Submit one (1) copy of application with attached separate sheets when necessary to complete all questions. Retain one (1) copy for your records. 2. Territorial and/or franchise agreements. 3. Each application shall be accompanied by a registration fee of $75.00 for each brand listed in Item 4, with a check or money order made payable to the “Commonwealth of Pennsylvania” or “PLCB” for the total amount. Remittances submitted by out-of-state applicants must be certified. or Act II of 2011 allows for up to (20) twenty brands to be registered for a single fee of $150.00 annually, so long as 100 barrels or less are produced on an annual basis. The 100 barrels or less box in question 4 must be checked. 4. A copy of the approved Application for the Certification/Exemption of Label/Bottle Approval, Form 5100.31 must be submitted for all new, revised (only when the label is changed, not size of contents) and specialty bottles or cans along with a copy of the label. This form can be obtained from their website at www.TTB.gov and can be completed on-line. DEFINITIONS 1. Franchisee:  For the purpose of brand registration, shall mean any person, limited liability company, corporation, partnership, or association in which rights have been conferred by a manufacturer of malt or brewed beverages to offer, sell and/or deliver its product(s) within or outside the Commonwealth. 2. Brand:  For the purpose of registration, Brand is defined as any malt or brewed beverage produced in accordance with a prescribed formula and sold under a distinct label, regardless of packaging configurations. For example, XYZ premium, XYZ lite, XYZ golden lite, XYZ pilsner, etc. would all be regarded as separate brands. INFORMATION (EXCERPTS OF ACT 14, 1987, SECTION 445 (PA. LIQUOR CODE) Section 445. Brand Registration. — No brand or brands of malt or brewed beverages shall be offered, sold or delivered to any trade buyer within this Commonwealth unless the manufacturer thereof shall first submit an application in the form and manner prescribed by the Board for the registration of the said brand or brands of malt beverages, together with an annual filing fee not to exceed seventy-five dollars ($75.00) for each brand registration requested. In the event an out-of-State or foreign manufacturer of malt or brewed beverages has granted franchise rights to any person for the sale and distribution of its brand products but which person is not licensed to sell and distribute the same in this Commonwealth, said such person shall nevertheless be required to register the involved brand before offering the same for sale in Pennsylvania. It is further conditioned that the person holding such franchise rights shall, together with its application for brand registration, file with the board copies of all agreements between it and the Pennsylvania importing distributor appointed by such person to sell and distribute the brands of malt or brewed beverages as provided by sections 431 and 492. Such agreement shall contain the manufacturer’s consent and approval to the appointment of the Pennsylvania importing distributor and the rights conferred thereunder. NOTE: Any importing distributor who accepts delivery of any brand of malt or brewed beverages which has not been registered with the Board by either the manufacturer or franchisee will be subject to penalty as determined by the Administrative Law Judge. Such sanctions may include fine, suspension or revocation of license privilege. IF YOU REQUIRE ASSISTANCE IN COMPLETING THE APPLICATION PACKET, CALL THE MALT BEVERAGE COMPLIANCE OFFICER AT (717) 265-8433. SEND THE APPLICATION PACKET TO: Pennsylvania Liquor Control Board, Attention: “Brand Registration”, P.O. Box 8940, Harrisburg, PA 17105-8940. American LegalNet, Inc. www.FormsWorkFlow.com