Application For A Permit To Purchase Permit # Alcohol And/Or Alcoholic Beverages Pursuant To Regulations Adopted By The Board On The 22ND Of August 1934 To The Commonwealth of Virginia Department of Alcoholic Beverage Control, Richmond, Virginia Application is Hereby Made by: (Name of Applicant) whose place of business is located at for the purchase of alcohol and/or alcoholic beverages pursuant to regulations adopted by the Virginia Alcoholic Beverage Control Board on the 22nd day of August, 1934. It is respectfully represented that the applicant is engaged in the following business: and manufactures the following products in which alcohol and/or alcoholic beverages are used: Name of Products Manufactured Kind of Alcohol And/Or Alcoholic Beverages Used That the estimated annual requirements of the applicant for alcohol and/or alcoholic beverages will be as follows: Kind of Alcohol And/Or Alcoholic Beverages Amount In Gallons The applicant agrees that if granted a permit to purchase such alcohol and/or alcoholic beverages, it will use the same for only such purposes as are lawful in the State of Virginia, and agrees to abide by the rules and regulations which now exist or may hereafter be adopted by the Virginia Alcoholic Beverage Control Board. Respectfully Submitted: For the year ending December 31, Applicant American LegalNet, Inc. www.FormsWorkflow.com