STATE OF VERMONT APPLICATION FOR LICENSE BY LICENSED MANUFACTURER OR RECTIFIER TO SELL VINOUS BEVERAGES (VT. FERMENTATION) 4th CLASS 20________ License Year: May 1 through April 30 of the following year.. ____________________________________________________________ Print Full Name of Person, Partnership, Corporation or LLC ____________________________________________________________ Make check payable to and Doing Business As – Trade Name mail to: ____________________________________________________________ Vermont Dept. of Liquor Control Street and street number or premises covered by this application Green Mountain Drive ____________________________________________________________ Montpelier, Vt. 05620-4501 Town or City & Zip Code ____________________________________________________________ Telephone Number Fee: $50.00 ____________________________________________________________ Mailing Address (if different from above) Application is hereby made for a 4th Class license by a licensed manufacturer or rectifier of vinous beverages to sell vinous beverages to the public provided that such beverages are produced by fermentation by the manufacturer or rectifier in Vermont 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 laws (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 beverages, records and papers in reference thereto; to keep such records as the Liquor Control Board may require; and upon hearing, the Liquor Control Board may at 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 statement, information or answers herein contained are false. Are you applying as (circle one) Individual, Partnership, Corporation, or LLC Please fill in name, address, social security number, date and place of birth of individual, partners, directors or members. Name Address SS# Date/ Place Birth Are all citizens of the United States and residents of Vermont?__________ If naturalized please fill in the following:: Name Court where naturalized Date American LegalNet, Inc. www.FormsWorkflow.com Please give name, title, date attended of a manager, director, partner who has attended a Liquor Control Education Seminar. Name _______________________Title _____________Date_____________ APPLICANTS: Describe fully the premises for which this application is made (i.e. type of construction, number of stories, location, etc.) Does applicant: Lease Rent Hold title to property Name and address of Lessor:___________________________________________________ _____________________________________________________________________________ Dated at _____________________________in County of ____________________ State of Vermont on this _______day of _______20______ I/We hereby certify under pains and penalties of perjury, that I/we are in good standing with respect to or in compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due to the State of Vermont on the date of this application (VSA, Title 32, sub section 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. . ______________________________________ Signature of authorized agent ________________________________________ Signature of Individual, partners, members American LegalNet, Inc. www.FormsWorkflow.com