WASHINGTON STATE LIQUOR CONTROL BOARD CLASS 5 PERMIT NO. ___________________ FEE: $10.00 No Fee for Federal Institution APPLICATIONS BY A MANUFACTURER FOR SPECIAL PERMIT TO IMPORT ALCOHOL, MALT, AND OTHER MATERIALS CONTAINING ALCOHOL TO BE USED IN THE MANUFACTURE OF LIQUOR, OR OTHER PRODUCTS. (RCW 66.20.010[5]) (Name of Business, if Different) (Firm’s Name) (Head Office if Different Location) (Address) (City) (Zip) (Phone) (State Nature of Business) (State specific purpose for which the specified material is to be used) Approximate amount of each material required prior to June 30, 2_____, when this permit will expire, is as specified in the following table: Kinds of Alcohol Required Lists Malts or Other Materials Containing Alcohol Required Total Quantity of Each Material in Gallons or Other Measure Required Annually Maximum of Each Name of Supplier and Material Desired to Shipping Point Purchase One Time in Gallons or in Other Measure This business is owned by (Federal, Individual or Private Company) I declare under the penalties of perjury and/or the revocation of any permit granted that I am the applicant or the authorized representative of the firm or corporation making this application and that the answers contained, including any accompanying information, have been examined by me and that the matters are true, correct and complete. Mail to: Date Washington State Liquor Control Board Licensing & Regulation PO Box 43098 Olympia WA 98504-3098 By Title Retain copy for your files. Approved: Date By LIQ 288-50 - 4/00 American LegalNet, Inc. www.FormsWorkflow.com