20___ STATE OF VERMONT Application for Wholesale Dealer’s License License Year: May 1st through April 30th of the following year. Fee of $1,000.00 Separate check for Solicitor Permits 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 _______________________________________________________ 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) Application is hereby made for a wholesale dealer’s license to sell and distribute at wholesale, malt and vinous beverages to retail dealers 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 license being granted, do promise and agree to comply with all law (state and local); 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 malt and vinous 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, or a druggist permit; and, upon hearing, the Liquor Control Board may in its discretion suspend or revoke such license 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 Corporation Company LLC Please fill name, address, social security number and place of birth of individual, partners, or directors (and stockholders) or members Name Address Office Are all the above citizens of the United States and residents of VERMONT? If naturalized citizen please fill the following: Name Court where naturalized Yes Location No (City, State/Zip) Date (Note: Resident Alien is not considered a U.S. citizen.) Have any of the above persons been convicted or pled guilty to any criminal or motor vehicle offense in any court of law? If yes, please attach a sheet explaining the offense, court and date. Yes No Have you registered your corporation and/or trade name with the Town Clerk? Are you registered with the Secretary of State to do business in Vermont? If a corporation, is your corporation chartered IN VERMONT? If so, give date Is your corporation charter still valid? Corporation Federal ID # Number of Federal Government Basic Permit Attach copy to application. Are the premises described in this application kept open during the reasonable business hours of the day, so that records may be checked and the premises inspected? American LegalNet, Inc. www.FormsWorkflow.com Describe fully the premises for which this application is made: Do you own the premises herein described? If not, do you lease the premises herein described? If leased, name and address of lessor who holds title to property HAVE YOU FILED THE REQUIRED BOND WITH THE LIQUOR CONTROL BOARD FOR THE ENSUING YEAR? *NOTE: For new applicants a bond of $1,000.00 must accompany this application. For renewals, you will be advised of the amount of bond that will be required. Have you any direct or indirect financial interest in the business of any person holding a first, second or third class licensee or druggist’s permit? Does any holder of a certificate of approval have any direct or indirect financial interest in the business covered by this application? Is there a church edifice or a building occupied in whole or in part as a public or parochial school within two hundred feet of the premises measured from the main entrance of the premises for which application is made to the main entrance of the church or school? License names of breweries or wineries you are to represent (attach sheet if necessary) The applicant must furnish to the Commissioner of Taxes, Montpelier, Vermont, on or before the 10th day of each month, a report, under oath, on a form prescribed and furnished by the Commissioner of Taxes, listing the quantity of malt and vinous sold by such licensee during the preceding calendar month. 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) The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories prior to acting on this application. I/We hereby certify that the information in this application is true and complete. Dated at in the County of State of Vermont, this day of and ,2004 (Applicant) (Signature of member of firm, officer or corporation or authorized agent) Sections 5111 and 5112 of the Internal Revenue code of 1954 require every wholesale dealer in alcoholic beverages to file a form annually and pay a special tax in connection with such sales activity. American LegalNet, Inc. www.FormsWorkflow.com