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Brewer Out Of State Application Form. This is a Utah form and can be use in Department Of Alcoholic Beverage Control Statewide.
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Tags: Brewer Out Of State Application, Utah Statewide, Department Of Alcoholic Beverage Control
UTAH DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL
1625 S 900 W • PO Box 30408 • Salt Lake City, UT 84130-0408 • Phone (801) 977-6800 • Fax (801) 977-6889
website: www.abc.utah.gov
Brewer (Located Outside Of Utah)
“CERTIFICATE OF APPROVAL”
APPLICATION CHECKLIST
Dear Applicant:
The items below must be completed and submitted before a certificate of approval can be issued by the Utah
Department of Alcoholic Beverage Control. Incomplete applications will not be accepted. The shipment of
beer to Utah beer wholesalers is not allowed until the certificate of approval is in effect.
1. ___ Application (form enclosed)
2. ___ Brand registration (form enclosed)
3. ___ Brand & territorial agreement(s) between brewer / agent and each beer wholesaler, reflecting
brands of beer / malt beverages and geographical areas for distribution (form enclosed)
4. ___ Copy of federal TTB brewer’s notice of approval to operate as a brewer
(if foreign brewer, send federal permit for importer / wholesaler and letter of appointment)
5. ___ Statement of alcohol analysis for each brand of beer / malt beverage as to actual alcohol content
(not more than 4.0% alcohol by volume or 3.2% by weight)
6. ___ Copy of label approval (“COLA”) from federal TTB reflecting actual brewer / producer,
and actual label for product shipped into Utah for each beer / malt beverage brand
(label must contain a statement as an alcoholic beverage, and may list alcohol content)
7. ___ $ 50 application fee (non-refundable)
8. ___ $250 annual certificate fee for period ending December 31 (refundable if certificate not granted).
> make check(s) payable to Utah Department of Alcoholic Beverage Control or UDABC
Enclosed for your information are copies of laws / rules pertaining to brewers located outside of Utah. If
you have any questions, please contact UDABC Licensing and Compliance at (801) 977-6800.
6.04.08
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UTAH DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL
1625 S 900 W • PO Box 30408 • Salt Lake City, UT 84130-0408 • Phone (801) 977-6800 • Fax (801) 977-6889
website: www.abc.utah.gov
Application for
BREWER (Located Outside Of Utah)
“CERTIFICATE OF APPROVAL”
NOTE: Please complete this application in the name of the actual producer of the beer / malt beverage products,
and list additional information regarding importing agent holding a federal permit (see #10).
1. Business Name of Actual Brewing
Company
2. Name of Brewing Ownership Entity (as listed in #9)
3. TTB Federal Permit # (if U.S. Brewer)
* please attach copy of TTB permit
4. Location Address
Street
City
State
Zip
Country
City
State
Zip
Country
.
5. Mailing Address
Street
or
PO Box
6. Business Phone(s)
Fax
7. Contact person
Phone Number
8. Local Representative (if any)
Phone Number
9. Ownership Entity (Check appropriate box and provide information in space below or attach sheet)
Individual (List information for individual)
Partnership (List information for all partners owning at least 20% of company)
Corporation (List information for stockholders owning at least 20% of company and all corporate officers)
Limited Liability Company / LLC (List information for members owning at least 20% of company)
TITLE
FULL NAME
6.04.08
PLACE OF RESIDENCE
% OWNED
BIRTH DATE
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10. Importing Company: Is a U.S. importer involved in the distribution / marketing of beer / malt beverages ?
[ ] Yes
[ ] No
If yes, please list information below:
11. Name of U.S. Importer
12. Registered Trade Names
13. TTB Federal Permit #
Permit Type
14. Mailing Address
Street or PO Box
City
15. Business Phone(s)
State
Zip
Fax
16. Contact person
Phone Number
17. Local Representative (if any)
Phone Number
18. Applicant agrees as a condition of issuing the certificate that they have read and will abide by the provisions
of the Alcoholic Beverage Control Act (Title 32A, Utah Code), all rules and directives of the department, and
understands that failure to adhere thereto shall constitute grounds for a fine, suspension or revocation of said
certificate.
19. The undersigned acknowledges that they have read and understands the statements made herein, certify that
the information contained herein is true and correct, and that execution of this application is done voluntarily and
by authorization of said organization.
Dated this ______ day of _____________________________,
.
____________________________________
Applicant / Business Name
____________________________________
Authorized Signature
____________________________________
Name / Title (please print)
STATE OF: _________________________
COUNTY OF: ___________________________
(or) COUNTRY OF: ____________________________
Subscribed & sworn to before me this ______ day of ___________________________,
.
_______________________________
Notary Public {& Seal}
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ALC
%
WT
AL.C
%
VOL
BREWER / BREWERY LOCATION(S)
(List Actual Producer of Beer)
FEDERAL
TTB PERMIT
NUMBER
NAME OF BREWER
ON TTB LABEL
APPROVAL
UTAH BEER DISTRIBUTOR(S)
& LOCATION(S)
DATE
6.04.08
page 4 of 8
Instructions: Use this form to register beer / malt beverage brands produced by certificate of approval holder; in addition, please submit: 1) copy of TTB label
approval for each brand and actual label for product shipped into Utah; 2) Analysis of alcohol content (not to exceed 3.2% alc/wt or 4.0% alc/vol); 3) notice of Utah
wholesaler / geographical area assigned for distribution (brand & territorial agreement form available).
BEER / MALT BEVERAGE
(Brand Name)
CERTIFICATE OF APPROVAL HOLDER (Brewing company as listed on application #1)
BRAND REGISTRATION FOR BEER / MALT BEVERAGES (3.2% Alc/Wt)
Brewer – Located Outside Utah “Certificate of Approval”
1625 S 900 W • PO Box 30408 • Salt Lake City, UT 84130-0408 • Phone (801) 977-6800 • Fax (801) 977-6889
UTAH DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL
UTAH DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL
1625 S 900 W • PO Box 30408 • Salt Lake City, UT 84130-0408 • Phone (801) 977-6800 • Fax (801) 977-6889
website: www.abc.utah.gov
“BEER - BRAND & TERRITORIAL AGREEMENT”
for Brewer and Utah Beer Wholesaler
Name of Brewer / Agent
Mailing Address
Is Agent a U.S. Importer ?
Street / PO Box
Contact
Person
City
Phone
State / Province
Zip/Postal
Code
Country
FAX
Pursuant to Utah Code 32A-11-102(1) (h&i), the brewer / agent hereby assigns the following brands of beer
(containing not more than 3.2% alc/wt or 4% alc/vol) to the Utah beer wholesaler listed below, for distribution
to licensed retailers within the described geographical area(s).
Utah Beer Wholesaler Company
Contact
Person
Phone
FAX
List brands of beer / malt beverage (3.2% alc/wt or 4% alc/vol) (attach list if necessary)
List geographical areas within Utah for beer distribution to licensed retailers (attach map is necessary)
Brewer / Agent
(Authorized Signature & Title)
Utah Beer Wholesaler
6.04.08
(Authorized Signature & Title)
Date
Date
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