20___ STATE OF VERMONT APPLICATION FOR CERTIFICATE OF APPROVAL FOR MANUFACTURER OR DISTRIBUTOR TO SELL MALT BEVERAGES License Year: May 1st through April 30th of the following year. Fee of $2,000.00 by CERTIFIED CHECK must accompany this application Make check payable to and mail to: VERMONT DEPARTMENT OF LIQUOR CONTROL GREEN MOUNTAIN DRIVE, DRAWER 20 MONTPELIER, VERMONT 05620-4501 _______________________________________________________ Print Full Name of Person, Partnership, Corporation or LLC _______________________________________________________ Street and street number or premises covered by this application _______________________________________________________ Town or City & Zip Code _______________________________________________________ Telephone Number Application is hereby made for a Certificate of Approval for Manufacturer or Distributor to sell malt beverages to wholesale dealers and bottlers under and in accordance with Title 7 of the Vermont Statutes annotated, as amended, and certify that all statements, information and answers to questions herein contained are true, and in consideration of such Certificate being granted, do promise and agree to comply with all regulations made and promulgated by the Liquor Control Board; to allow the Liquor Control Board, and any of their assistants and investigators, to examine at any time the premises, supply of beverages, records and papers in reference thereto; to keep such records as the Liquor Control Board may require; and not have any direct or indirect financial interest in any person holding a Vermont first, second or third class License, wholesale dealer’s or bottler’s license, and, upon hearing, the Liquor Control Board may in its discretion suspend or revoke such Certificate whenever it may determine that the law or any regulations of the Liquor Control Board have been violated, or that any statements, information or answers herein contained are false. Are you applying as (circle one): Individual Partnership LLC Please fill name and address of individual, partners, or principal officers (attach sheet if necessary) Name Address Corporation Office If a corporation or LLC, in what state is your corporation or LLC chartered? If NEW APPLICANT or LLC attach Articles of Organization; if corporation attach copy of charter. Is your corporate charter still valid? Corporation or LLC Federal ID# Number of Federal Government Basic Permit: Attach copy to this application. Do you hold a license or permit issued by a control board IN YOUR STATE authorizing the sale of malt beverages? Attach copy to this application. Address and description of warehouse if located in Vermont Does the applicant understand that he can sell and deliver only to persons within Vermont who hold wholesale dealer or bottlers license issued by the Liquor Control Board Name and address of Vermont Wholesale Dealer The applicant must furnish to the Commissioner of Taxes, Montpelier, Vermont on or before the 20th day of each month, a report, under oath, on a form prescribed and furnished by the Commissioner of Taxes, showing the quantity of malt beverages sold or delivered to each wholesale dealer within the State of Vermont during the preceding calendar month. Dated at in the County of and State of day of this , , 20 I/We hereby certify, under pains and penalties or perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application (VSA, Title 32, § 3113). I/We hereby certify that the information in this application is true and complete. (Applicant) (Signature of member of firm, officer or corporation or authorized agent) American LegalNet, Inc. www.FormsWorkflow.com