APPLICATION FOR AGENT'S PERMIT (A) AGENT'S BEER LICENSE (BK), MANUFACTURER'S AGENT'S PERMIT (T), AND DISTILLER'S AGENT'S PERMIT (DK) ISSUE DATE FEE SURCHARGE L-AGENT (01/2018) LATE FEE TABC USE ONLY A BK T DK 1A. APPLICATION FILED FOR: A AGENT'S PERMIT (Must be 18 yrs. old) Registry No. BK AGENT'S BEER LICENSE (Must be 18 yrs. old) T MANUFACTURER'S AGENT'S PERMIT (Must be 18 yrs. old) DK DISTILLER'S AGENT'S PERMIT (Must be 21 yrs. old) APPLICATION FILED FOR: Original C. ABKNotification of New Employer TDKProvide current License/Permit No(s) for notification of new employer. B. FOR AGENT 2. Social Security Number Issuing State and Driver License Number Date of Birth (mm/dd/yyyy) Full Legal Name (Last, First, Middle) 3. Permanent Mailing Address City 4. Area Code + Business Telephone Number County Area Code + Alternate Telephone Number E-mail Address State Zip Code (9 digits) FOR EMPLOYER(S) 5. List the name(s) and address(es) of employer(s). (If more space is needed, attach additional page). The person whose name and address appears in Question 2 and 3 is hereby designated as our authorized agent. Name of License/Permit Holder (Employer): Street Address: City, County, State, Zip Code: License/Permit No. of Wholesaler/Distributor/Manufacturer/Distiller: Name of License/Permit Holder (Employer): Street Address: City, County, State, Zip Code: License/Permit No. of Wholesaler/Distributor/Manufacturer/Distiller: Signature of authorized representative of employer: SIGN HERE: TABC USE ONLY Signature of authorized representative of employer: SIGN HERE: FOR TABC USE ONLY WRITTEN PROCESS DATE / / END PROCESS DATE / / American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2 L-AGENT (01/2018) ALL AGENTS 6. Has applicant been convicted of a felony or any provision of the Alcoholic Beverage Code or any rule of the Texas Alcoholic Beverage Commission? If "YES," specify: 6. YES NO 7. Does the applicant or anyone with whom applicant is residentially domiciled have any interest directly or indirectly in the finances, premises, business, equipment or fixtures of a permittee or licensee of a different level in this state? If "YES," specify: 8. Has applicant loaned, given, or furnished any money, service or any other thing of value to any retailer in this State? If "YES," specify: 7. YES NO 8. YES NO WARNING: Section 101.69 of the Texas Alcoholic Beverage Code is as follows: "...a person who makes a false statement or false representation in an application for a permit or license or in a statement, report, or other instrument to be filed with the Commission and required to be sworn commits an offense punishable by imprisonment in the Texas Department of Criminal Justice for not less than 2 nor more than 10 years." ACKNOWLEDGMENT PRINT NAME: NAME MUST APPEAR AS NAME SHOWN IN QUESTION 2 SIGN HERE: SIGNATURE MUST APPEAR AS NAME SHOWN IN QUESTION 2 Before me, the undersigned authority, on this day of , 20 the person whose name is signed to the foregoing application personally appeared and, duly sworn by me, states under oath that he or she read the said application and that all the facts therein set forth are true and correct. SIGN HERE: NOTARY PUBLIC (S E A L) ALL AGENTS INSTRUCTIONS 1. 2. 3. LICENSES/PERMITS ARE ISSUED FOR A TWO-YEAR PERIOD. Fees may NOT be prorated or refunded. Send the original application with the proper fee and surcharge to the Texas Alcoholic Beverage Commission, P.O. Box 13127, Austin, Texas, 78711. Keep a copy for your record. Fees and surcharges shown below must be made payable to the Comptroller of Public Accounts. Class of Permit or License State Fee Surcharge Total Due Agent's Permit (A) $20.00 $94.00 $114.00 Agent's Beer License (BK) $20.00 $94.00 $114.00 Manufacturer's Agent's Permit (T) $20.00 $94.00 $114.00 Distiller's Agent's Permit (DK) $20.00 $94.00 $114.00 ENSURE YOUR EMPLOYER(S) HAS (HAVE) SIGNED THE APPLICATION IN THE SPACE(S) PROVIDED IN QUESTION 5. THE EMPLOYER MUST HOLD A VALID LICENSE/PERMIT ISSUED BY THE TEXAS ALCOHOLIC BEVERAGE COMMISSION OR MUST BE IN THE PROCESS OF APPLYING FOR SUCH. If applying for both Agent's Beer License (BK) and Agent's Permit (A), the license number of the General Distributor's License (BB) or Branch Distributor's License (BC) and permit number of the Wholesaler (W) or General Class B Wholesaler's (X) must be shown. Applicants for a Manufacturer's Agent's Permit (T) must indicate Nonresident Seller's Permit (S) number. Applicants for a Distiller's Agent's Permit (DK) must indicate the Distiller's and Rectifier's Permit number (D). You may not hold both a Manufacturer's Agent's Permit (T) and Agent's Permit (A). You may hold a combination of permits/licenses as long as they represent the same tier of the industry. All licenses and permits expire 2 years from issue date. 4. 5. 6. 7. American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 L-AGENT (01/2018)