APPLICATION FOR FORWARDING CETNER AUTHORTIY (ONLY THE HOLDERS OF THE FOLLOWING PERMIT/LICENSE CLASSES MAY OBTAIN THIS AUTHORITY: MANUFACTURER’S LICENSE, NONRESIDENT MANUFACTURER’S LICENSE, BREWER’S PERMIT, DISTILLER’S AND RECTIFIER’S PERMIT, WINERY PERMIT AND NONRESIDENT BREWER’S PERMIT.) TABC USE ONLY TYPE OR PRINT IN INK FORM L-105 (9/2011) ISSUE DATE / FC - FEE $2,000 / SURCHARGE LATE FEE (RENEWAL ONLY) $278 1A. APPLICATION FILED FOR: Original Renewal Change Change: Registry No. B. If renewal or change, enter Authority Number: FC 2. APPLICATION IS FILED BY: ALL APPLICANTS (Indicate current manufacturing license or permit number issued by Texas and the name of entity currently holding license or permit.) TABC License/Permit Number: Entity Name: 3. 4. Name of Regional Forwarding Center Address or Location City County State 5. Mailing Address 6. Area Code + Business Telephone Number Area Code + Alternate Telephone Number ( ( City Zip Code (9 digits) State Zip Code (9 digits) TABC USE ONLY - ) - ) E-mail Address (optional) - PROCESSOR REVIEW DATE / / WRITTEN PROCESS DATE END PROCESS DATE / / / / PROCESSOR I.D. American LegalNet, Inc. www.FormsWorkFlow.com PARTNERSHIPS/CORPORATIONS TRADE NAME: FORM L-106-PC (8/2005) 1A. Indicate type of ownership and complete the information below: Corporation Limited Liability Company Partnership Limited Partnership Limited Liability Partnership B. Federal Employer’s I.D. No.: C. Entity Name: D. Charter No.: Date Approved: / / State: FOR ALL OFFICER(S), PARTNER(S), DIRECTOR(S), MANAGER(S), STOCKHOLDER(S) AND MEMBER(S). E. Number and class of shares, memberships or units issued: 2. COMPLETE THE FOLLOWING PER INSTRUCTIONS: Social Security Number - Issuing State and Driver’s License Number Full Legal Name (Last, First Middle) Officer Partner Director/ Manager Date of Birth (mm/dd/yyyy) / / Stockholder/ Member Residential Address Social Security Number - Full Legal Name (Last, First Middle) Officer Partner Director/ Manager Date of Birth (mm/dd/yyyy) / / Stockholder/ Member Residential Address Social Security Number - Issuing State and Driver’s License Number Officer Partner Director/ Manager Date of Birth (mm/dd/yyyy) / / Stockholder/ Member Residential Address Full Legal Name (Last, First Middle) Officer Partner Director/ Manager Date of Birth (mm/dd/yyyy) / / Stockholder/ Member Residential Address Social Security Number - Full Legal Name (Last, First Middle) Officer Partner Director/ Manager Date of Birth (mm/dd/yyyy) / / Stockholder/ Member Residential Address Social Security Number - Full Legal Name (Last, First Middle) Residential Address Officer Partner Director/ Manager Date of Birth (mm/dd/yyyy) / / Stockholder/ Member State Zip Code (9 digits) - Class & No. Shares Held or % Memberships or % Interest State Zip Code (9 digits) - Class & No. Shares Held or % Memberships or % Interest State Zip Code (9 digits) - Class & No. Shares Held or % Memberships or % Interest Title City Issuing State and Driver’s License Number Class & No. Shares Held or % Memberships or % Interest Title City Issuing State and Driver’s License Number Zip Code (9 digits) - Title City Issuing State and Driver’s License Number State Title City Full Legal Name (Last, First Middle) Social Security Number - Title City Issuing State and Driver’s License Number Class & No. Shares Held or % Memberships or % Interest State Zip Code (9 digits) - Class & No. Shares Held or % Memberships or % Interest Title City State Zip Code (9 digits) - (IF YOU NEED ADDITIONAL SPACE FOR MORE NAMES, USE ADDITIONAL COPIES OF THIS PAGE) American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR FORWARDING CETNER AUTHORTIY CONTINUED TRADE NAME: FORM L-105 (9/2011) PLEASE READ THIS IMPORTANT STATEMENT BEFORE SIGNING THIS APPLICATION. The holder of this authority may have an interest directly or indirectly, in on only the manufacturing level of the Alcoholic Beverage Industry. You or your agent, servant, or employee, including 3rd party operators, may not be employed in any capacity at wholesale or retail levels, may not rent or lease property or equipment from or to an entity operating at wholesale or retail levels, may not secure credit or a loan in any form for an entity at wholesale or retail levels, cannot control in any fashion the interests of a permittee or licensee at wholesale or retail levels. 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 penitentiary for not less than 2 nor more than 10 years.” ACKNOWLEDGMENT ACKNOWLEDGMENT If Applicant is: Who Must Sign: Individual Individual Owner Partnership Corporation Limited Partnership Limited Liability Partnership Limited Liability Company PRINT NAME: Partner NAME OF MANUFACTURER SIGN HERE: Officer SIGNATURE OF MANUFACTURER General Partner Before me, the undersigned authority, on this General Partner , 20 Office or Manager day of 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 SEAL CERTIFICATE OF CITY SECRETARY CERTIFICATE OF CITY SECRETARY (if not in incorporated city, so state) I hereby certify on this day of indicated in question 4 as the place of business is in a “wet area,” for , 20 , the location Beer / Wine / Distilled Spirits (Circle all that apply) and that such location is inside the boundaries of this city.. SIGN HERE: , Texas City Secretary/Clerk SEAL CERTIFICATE OF COUNTY CLERK CERTIFICATE OF COUNTY CLERK I hereby certify on this day of indicated in question 4 as the place of business is in a “wet area,” for. , 20 , the location Beer / Wine / Distilled Spirits (Circle all that apply) SIGN HERE: County County Clerk SEAL American LegalNet, Inc. www.FormsWorkFlow.com