VIRGINIA DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL APPLICATION FOR GRAIN ALCOHOL PERMIT INSTRUCTIONS There is no charge for this permit. Complete and return application to: LICENSE RECORDS MANAGEMENT VIRGINIA DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL 2901 HERMITAGE ROAD P O BOX 27491 RICHMOND VA 23261-7491 BUSINESS Company name Steet address City County Virginia ZIP+4 PURPOSE Intended use: PURCHASING Purchase to be made from ABC store number: Store address City County Virginia Estimate the amount of 190 proof grain alcohol required: BOTTLE SIZE ZIP PER MONTH OR PER YEAR G 375 ML G 1.75 L APPLICANT Applicant name Daytime phone number Title Signature 805-75 American LegalNet, Inc. www.FormsWorkflow.com FOR OFFICE USE ONLY SPECIAL AGENT Purpose: G Culinary G Commercial G Industrial G Medical Comments: Recommendation: G Approval G Denial Signature Territory number Date SPECIAL AGENT IN CHARGE Permit number Effective date Special Agent assigned Date City/County Purpose: District G Culinary Recommendation: Signature G Commercial G Approved G Industrial G Medical G Denied Date American LegalNet, Inc. www.FormsWorkflow.com