Commonwealth of Virginia Department of Alcoholic Beverage Control Application for Off Premises Keg Permit ABC License Number: Licensee Name: Trade Name: Street Address: Zip: State: City: Pursuant to §3VAC5-70-180 of the Virginia Department of Alcoholic Beverage Control Regulations No person licensed to sell wine or beer at retail for off-premises consumption, or any officer, agent or employee thereof, shall sell any such alcoholic beverage in a keg without having (i) obtained a permit pursuant to subsection B authorizing such sales, (ii) registered the sale on a form prescribed by the board, and (iii) affixed a registration seal on the keg at the time of sale; provided, if the purchaser takes possession of the keg at the premises of the wholesale licensee pursuant to subsection G, the wholesale licensee shall affix the registration seal. This is the application for an Off Premises Keg Permit. Only an owner of the business, a partner, if the business is a partnership, a member of a limited liability company or an officer of a corporation, if the business is a corporation is authorized to sign this application. Once the application has been signed, return it, along with the annual fee, to: Department of Alcoholic Beverage Control License Records Management P. O. Box 27491 Richmond, VA 23261-7491. Note: After the payment of the initial keg permit fee, the annual fee will be billed as part of the license renewal. Print Name Title Date Signature 805-45 Rev. 7/98 American LegalNet, Inc. www.FormsWorkflow.com