1350 STATE OF SOUTH CAROLINA DEPARTMENT OF REVENUE Alcohol Beverage Licensing KEG REGISTRATION FORM ABL-907 (Rev. 10/23/07) 4362 (Required on all Kegs Sold to Retail Purchaser with a Capacity of over 5.16 Gallons) Note to License Holder: This form must be kept for a minimum of 90 days from the date of purchase and be made available for inspection by the Department or appropriate law enforcement agencies. Keg Identification Number: _____________________________________________________________ Name of License Holder: _______________________________________________________________ License Holder’s Address: ______________________________________________________________ License Holder’s License or Permit Number: _______________________________________________ Name of Purchaser: _________________________________ Date of Purchase: __________________ Purchaser’s Address: __________________________________________________________________ Purchaser’s Date of Birth: ___________________ Number of Kegs Purchased: _______________ Purchaser’s Driver’s License or Identification Card Number: ___________________________________ Purchaser’s Acknowledgement: The undersigned Purchaser, does hereby attest to the accuracy of the purchaser’s information, as indicated above; and that he or she acknowledges that unless otherwise permitted by law, it is unlawful to transfer beer to a person under the age of twenty-one; and that unless otherwise permitted by law, the beer in the keg that is being purchased will not be consumed by a person under the age of twenty-one. Purchaser License Holder shall fill out all information requested below at appropriate time: Date Returned _____________ Returned with Keg ID Tag(s) Properly Affixed: Yes _____ No ______ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Detach Here - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Alcohol Beverage Licensing KEG REGISTRATION FORM ABL-907 (Rev. 10/23/07) 4362 Note to License Holder: You must indicate below, and provide this receipt to the Purchaser, indicating whether the keg(s), when returned, had the Keg ID Tag(s) properly affixed. Keg Identification Number(s): ______________________________________________________________________ Returned with Keg ID Tag(s) Properly Affixed: Yes _____ No ______ Date Keg(s) Returned: __________________ Signature of License Holder or Authorized Representative: ______________________________________ 43621010 American LegalNet, Inc. www.FormsWorkFlow.com