A P P L I C A T I O N F O R O U T - O F -S T A T E W I N E R Y DIRECT SHIPPER’S PERMIT TABC USE ONLY TRADE NAME: FORM L-106 (9/2011) ISSUE DATE DS - / FEE $150 / SURCHARGE LATE FEE (RENEWAL ONLY) $376 FIRST READ ALL INSTRUCTIONS - TYPE OR PRINT IN INK 1. APPLICATION IS FOR: Registry No. Original Renewal/Change Change of: If renewal or change, enter the Permit No. DS- ALL APPLICANTS 2. APPLICANT IS: Individual Limited Partnership Corporation Limited Liability Company Limited Liability Partnership Partnership Other: 3. Trade Name of Business 4. Address of Location (must be in the United States) City State Zip Code (9 digits) - 5. Mailing Address City State Zip Code (9 digits) - 6. Business Telephone Number ( ) - Alternate Telephone Number ( ) E-Mail Address (optional) - 7. Provide the applicant’s Texas Sales Tax Permit Number: NOTE: Your application cannot be approved without a valid Texas Sales Tax Permit Number. 8. Does the applicant hold a Winery Permit in the State of Texas? 8. YES NO 9. Does the applicant operate a winery located in the United States and hold all state and federal permits necessary to operate the winery, including the federal winemaker’s and blender’s basic permit? 9. YES NO If “YES,”please indicate your TTB Permit Number: INDIVIDUALS INSTRUCTIONS: If Individual Owner, complete question 10. For all others, refer to Instructions on this page. 10. Social Security Number - Issuing State / Driver’s License Number - / INSTRUCTIONS / 11. Full Legal Name (Last, First, Middle) 12. Permanent Mailing Address City State Zip Code (9 digits) - 13. Residential Address City State Zip Code (9 digits) INSTRUCTIONS FOR: CORPORATIONS, LIMITED LIABILITY COMPANY, PARTNERSHIP, LIMITED PARTNERSHIP, LIMITED LIABILITY PARTNERSHIP, OTHER. For Corporations or Limited Liability Companies: Complete L-106-PC for all officer(s), partner(s), director(s), manager(s), stockholder(s), and member(s). For Partnership, Limited Partnership, or Limited Liability Partnership: Complete L-106-PC ensuring you include all partners involved in business. If one or more of your general or limited partners is a limited partnership or limited liability partnership complete L-106-PC for each partnership. If one or more of your general or limited partners is a corporation: Complete L-106-PC for each corporation or limited liability company. If applicant is a publicly held corporation: Provide pertinent information as indicated in 2 on L-106-PC on all stockholders holding 5% or more of the shares. INITIAL APPLICATION INCOMPLETE TABC USE ONLY Date of Birth (mm/dd/yyyy) YES - NO YES - NO PROCESS DATE: / ADDITIONAL CORRESPONDENCE PROCESSOR I.D.: / PROCESSOR REVIEW DATE: / / PROCESSOR ERROR YES - NO Page 1 of 3 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) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com A P P L I C A T I O N F O R O U T - O F -S T A T E W I N E R Y DIRECT SHIPPER’S PERMIT CONTINUTED TRADE NAME: FORM L-106 (9/2011) ACKNOWLEDGMENT ALL APPLICANTS The applicant or permit and license holder may have an interest, directly or indirectly in only one level of the alcoholic beverage industry; i.e., manufacturing, wholesaling or retailing. You or your agent, servant or employee may not be employed in any capacity at different levels, may not rent or lease property or equipment from or to an entity operating at another level, may not secure credit or a loan in any form for an entity at another level, cannot control in any fashion the interests of a permittee or licensee at a different level. 15. Are you or anyone indicated in questions 10 on L-106 or 2 on L-106-PC in violation of the above requirements? If “YES,” explain below or attach page: 16A. Has any person named in questions 10 on L-106 or 2 on L-106-PC or his or her spouse been finally convicted or received deferred adjudication for a felony offense? B. If answer to 12A is “YES,” has it been five years since the termination of a sentence, parole or probation served for any offenses indicated above? If “NO,” attach an explanation. C. Has any person named in questions 10 on L-106 or 2 on L-106-PC been convicted of any offense(s) under federal or state law, or municipal ordinance involving violations of an individual’s civil rights or discrimination against an individual on the basis of race, color, creed or national origin? YES NO 12A. YES NO B. YES NO C. 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 penitentiary for not less than 2 nor more than 10 years.” ACKNOWLEDGMENT If Applicant is: Individual Partnership Corporation Ltd. Partnership Ltd. Liability Partnership Ltd Liability Co. Who Must Sign: Individual Owner Partner Officer General Partner I, the applicant, expressly submit to personal jurisdiction in Texas state and federal courts and expressly submit to venue in Travis County, Texas, as proper venue for any proceedings that may be initiated by or against the commission. General Partner SIGN HERE: Officer or Manager PRINT NAME: SIGNATURE MUST APPEAR AS NAME SHOWN IN QUESTION 10 on L-106 OR 2 ON L-106-PC. Before me, the undersigned authority, on this day of , the person whose name is signed to the foregoing application personally 20 appeared and, duly sworn by me, states under oath that he or she has read the said application and that all the facts therein set forth are true and correct. (SEAL) INSTRUCTIONS 11. SIGN HERE: NOTARY PUBLIC 1. Beginning January 1, 2009 the permit covered under this form will be issued for a two-year period. You MUST renew for the entire two-year period. The total amount of fees plus surcharges to cover the two-year period MUST be paid at the time of renewal. Fees may NOT be prorated or refunded. 2. Prepare the application in duplicate. Mail the original application to the Texas Alcoholic Beverage Commission, P.O. Box 13127, Austin, Texas 78711 with the correct permit fees. Keep duplicate for your files. 3. Fee must be paid with Cashier’s Check, Money Order, or Firm Check from a corporate permittee made payable to the Comptroller of Public Accounts. We will not accept personal checks. The fees and surcharges are shown below: Class of Permit Annual State Fee *Surcharge Effective 9/1/2011 Total Due Out-Of-State Winery Direct Shipper’s Permit $150.00 $376.00 $526.00 4. *Surcharges are subject to annual change. The surcharges assessed each year are determined by the Texas Alcoholic Beverage Commission and not by the Legislature. The Legislature determines the total dollar amount to be raised in agency revenue. The revenue is comprised of fees, which are set by the Legislature, and the surcharges which are determined by the agency. 5. Tax security is required in an amount of $1,000 to adequately protect the state against the anticipated tax liability and may be submitted as a: liquor tax bond from a surety company authorized to do business in Texas, or, a letter of credit, or, assignment of certificate of deposit or savings account from a Texas bank or credit union. These forms are available on the Texas Alcoholic Beverage Commission website at www.tabc.state.tx.us. 6. To obtain a Sales and Use Tax Permit access the Texas Comptroller’s web site at www.window.state.tx.us. Should you require additional assistance contact Tax Assistance at (800) 252-5555. Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com