2901 Hermitage Road, Richmond, Virginia 23220 Pursuant to Virginia Code § 4.1-310, the Virginia Alcoholic Beverage Control Board may issue a permit to allow any adult (age 21 or older) moving to Virginia to bring his alcoholic beverages into the state as part of his household goods. A permit will be issued for only one case of alcoholic beverages for each adult family member. However, an exception will be made to the one case limitation if an adult fills out the attached application and certifies under oath or affirmation before a notary that the alcoholic beverages have been in the applicant’s possession for at least SIX MONTHS prior to applying for the permit. American LegalNet, Inc. www.FormsWorkflow.com COMMONWEALTH OF VIRGINIA DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL VIRGINIA ALCOHOLIC BEVERAGE BOARD RICHMOND APPLICATION: PERMIT TO IMPORT ALCOHOLIC BEVERAGES IN PERSONAL OR HOUSEHOLD EFFECTS OF PERSON MOVING RESIDENCE TO VIRGINIA, AS PROVIDED IN SECTION 4.1-310 OF THE CODE OF VIRGINIA. This application must be completed and notarized before a permit may be issued. 1. Name of alcoholic beverage owner: 2. Address of former residence: 3. Length of time at former residence: 4. Address of Virginia residence: 5. Quantity of each type of: alcoholic beverage involved, (spirits, wine, beer, etc.): [attach additional sheet if necessary] 6. Time period during which alcohol was accumulated at former residence: 7. Location of alcoholic beverages at this time: 8. Name and address of individual or carrier who will transport alcoholic beverages into or through the Commonwealth of Virginia: ******************************* I hereby certify that the above-described alcoholic beverages were accumulated by me while residing at my former residence as a part of my personal or household effects; that the alcoholic beverages have been in my possession for at least six months; that the alcoholic beverages are intended only for the use of myself, my family and guests, and the merchandise will not be sold, dispensed or given away contrary to law. I understand that any alcoholic beverages not meeting the above requirements may be subject to taxes and other charges provided by law. Signature and Date NOTARIZATION REQUIRE BELOW: City of , State of Sworn before me on this day of , . Notary My commission expires the Rev. (December 2000) day of , . American LegalNet, Inc. www.FormsWorkflow.com