ABL-107-B STATE OF SOUTH CAROLINA DEPARTMENT OF REVENUE APPLICATION FOR CERTIFICATE OF REGISTRATION OF PRODUCER REPRESENTATIVE Mail to: SC Department of Revenue, ABL Section, Columbia, SC 29214-0904. (Rev. 7/29/03) 4290 For Office Use Only File Number License Period Ending DLN DLN Amount Paid 14-3951-0006 SLED 34-3973-9000 In accordance with Chapter 7, Title 61, Code of Laws for SC, 1976, as amended, the undersigned does hereby make application for a Certificate of Registration as the South Carolina representative of the following Registered Producer: Registered producer and address: and for that purpose submit the following information: 1. Name: Social Security Number: 2. Home Address: Zip Code: 3. Business Address: Zip Code: 4. Are you a resident of South Carolina? Must be a resident of South Carolina for 30 days prior to applying. How long? 5. Do you have a direct of indirect interest in a wholesale or retail liquor business in South Carolina? Yes No 6. Telephone number where you can be reached during business hours: 7. Fee - $250.00 (must be submitted with this application) 8. I do hereby certify that the SC Department of Revenue shall have the right within statutory limitations to audit and examine the books and records, papers, and memoranda of the applicant, with respect to the administration and enforcement of laws administered by the SC Department of Revenue and the South Carolina Law Enforcement Division. STATE OF SOUTH CAROLINA COUNTY OF PERSONALLY appeared who being duly sworn says: that the information given above is true and correct to the best of his knowledge and belief. Sworn and subscribed before me this day of , APPROVED BY CERTIFICATE ISSUED: 42901017 (Applicant Sign Here) (enter year) Date YES NO Date American LegalNet, Inc. www.FormsWorkflow.com