Date Received_________________ Date Issued___________________ License No.________________________ South Dakota Alcoholic Beverage Carrier License Application Mail to: South Dakota Department of Revenue & Regulation, Special Tax Division, 445 East Capitol Ave, Pierre, SD 57501-3185 A. Owner Name and Address B. Business Name and Mailing Address Telephone #: C. Vehicle License Numbers: Carrier’s license: $100.00 per calendar year (Mark one) New License____________ Re-issuance____________ Certificate: The undersigned applicant certifies under the penalties of perjury, that all statements herein are true and correct; that the said applicant complies with all of the statutory requirements for the class of license being applied for and in additional agrees to permit agents of the Department of Revenue access to records and agrees this application shall constitute a contract between applicant and the State of South Dakota entitling the same or any peace officers to inspect books and records of the applicant for the purpose of enforcing the provisions of Title 35 SDCL, as amended. Signed this ______ day of _________________, 20_____ Signature ________________________________________ For Department of Revenue use only Amount of license fee collected: ______________ STATE LIQUOR AUTHORITY: APPROVAL ___________ REVIEW___________ Date deposited:___________________________ Deposited by:________________ Corporation applicants please complete other side American LegalNet, Inc. www.FormsWorkflow.com Corporate Supplement Name of Corporation:________________________________________________________________________________ Address of office & principal place of business:___________________________________________________________ Name, Title and Address of corporate officers: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Name, Address of corporate directors: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Signature of one corporate officer: _________________________________________________________ Date:___________________________________ American LegalNet, Inc. www.FormsWorkflow.com