20 ___ STATE OF VERMONT APPLICATION FOR SHIPPING PERMIT License Year: May 1st through April 30th of the following year. __________________________________________________________ Licensee Number __________________________________________________________ Print Full Name of Person, Partnership, Corporation or LLC __________________________________________________________ Doing Business As – Trade Name __________________________________________________________ Street and street number or premises covered by this application __________________________________________________________ Town or City & Zip Code __________________________________________________________ Telephone Number __________________________________________________________ Mailing Address (if different from above) Circle one: Second Class Fourth Class ANNUAL FEE: $200.00 Make check payable to and mail to: VERMONT DEPARTMENT OF LIQUOR CONTROL GREEN MOUNTAIN DRIVE, DRAWER 20 MONTPELIER, VERMONT 05620-4501 Permit for licensees who sell vinous beverages ONLY. (If malt beverages are being sold - licensee does NOT qualify for this permit.) Manufacturer Rectifier To the Liquor Control Board, Montpelier, Vermont. Application is hereby made for a shipping permit to ship vinous beverages under and in accordance with Title 7, Vermont Statutes Annotated, as amended, and certify that all statements, information and answers to questions herein contained are true; and in consideration of such permit being granted do promise and agree to comply with all local and state laws; and to comply with all regulations made and promulgated by the Liquor Control Board. Upon hearing, the Liquor Control Board may, in its discretion, suspend or revoke such permit whenever it may determine that the law or an regulations of the Liquor Control Board have been violated, or that any statement, information or answers herein contained are false MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE PERMIT, AFTER NOTICE AND HEARING. _____________________________________________________________________________________ Sec. 2a. 7 V.S.A. § 66 SHIPPING PERMIT, VINOUS BEVERAGES, DELIVERY REQUIREMENTS reads: (a) The department may grant a shipping permit to a second class licensee, provided that vinous beverages are the only alcoholic beverages sold by the licensee, to a fourth class licensee or to a holder of a license to manufacture or rectify vinous beverages, provided the licensee annually files an application in a form required by the department accompanied by an annual fee of $200.00. (1) A holder of a fourth class license or a license to manufacture or rectify vinous beverages granted a shipping permit under this section may deliver to an individual purchaser for personal consumption no more than one case of no more than 12 bottles of vinous beverages per shipment or effect delivery of that amount of vinous beverages by a common carrier, as defined in 5 V.S.A. § 1821, that delivers primarily freight or express. (2) A holder of a second class license granted a shipping permit under this section may effect delivery of vinous beverages only by common carrier as required by this section. (b) Vinous beverages shall be delivered pursuant to an invoice that includes the name of the licensee and the name and address of the purchaser. The vinous beverages shall be delivered only to the address on the invoice and only to an individual who is age 21 or over. The name and address American LegalNet, Inc. www.FormsWorkflow.com of the common carrier to be used must be filed with this department. The licensee shall file a copy of the invoice with the department prior to shipping and shall retain a copy of the invoice for two years. (c) A licensed manufacturer or rectifier holding a shipping permit shall pay directly to the Commissioner of Taxes the tax on vinous beverages as required by subsection 421(a) of this title shipped pursuant to this section. (d) A holder of a shipping permit under this section shall not deliver or have delivered any vinous beverages to any person under the age of 21. (e) A common carrier shall not deliver vinous beverages until it has complied with the provisions of subsections 239(a) and (b) of this title, and its compliance has been certified by the Department of Liquor Control. No employee of a common carrier shall deliver vinous beverages until that employee completes the training required by subsection 239(c) of this title. (f) For any violation of this section, the Board of Liquor Control shall have the power to suspend or revoke a certification or permit issued under this section. Prior approval must be received from Department of Liquor Control before delivery can be made. ALL APPLICANTS MUST COMPLETE AND SIGN THE FOLLOWING I/We hereby certify that vinous beverages are only sold from the above licensed premises and that the information in this application is true and complete. Dated at __________________________________ in the County of _________________________ and State of Vermont, this ________________________ day of ________________________, 20______ Signature of authorized agents of licensee: ___________________________________________ _______________________________________ ___________________________________________ Title _______________________________________ American LegalNet, Inc. www.FormsWorkflow.com