STATE OF WEST VIRGINIA DEPARTMENT OF TAX AND REVENUE ALCOHOL BEVERAGE CONTROL ADMINISTRATION 322 70th Street, SE Charleston, West Virginia 25304-2900 INSTRUCTIONS FOR REPRESENTATIVE’S LICENSE (FORM # ABCC-WS-181) 1. General Information Please read the instructions carefully. All questions are to be answered in full. Your accuracy and thoroughness in completing the application form will assist us in processing the application and preventing unnecessary delays. 2. False representations made in application or failure to comply with Chapter 60 of the West Virginia Code (State Control of Alcoholic Liquors) and rules and regulations promulgated thereunder may result in denial, revocation, or suspension of the license. 3. An organizational chart detailing those individuals authorized to represent each of your respective companies in this state must accompany the application. This should include any company executive who has either visited this office in the past or intends to visit at a future date. 4. License fees must be paid by certified check, cashier’s check, company check, or money order. Personal check or cash will not be accepted. The representative license period begins on July 1 and ends June 30 of each year. There is no cost to license as a representative of a Wine Distributor. The cost of a Distillery/Wine Supplier Representative’s license is one hundred dollars ($100.00) for a full year. If the license is issued for less than a full year, the fee may be prorated as follows: License Application Submitted License Fee July 1 through June 30 January 1 through June 30 Full License Fee ½ of License Fee If you have any questions, please call (304) 558-2481 and ask for the Spirits & Wine Division. Return to: (304) 558-2481 West Virginia ABC Commission Spirits, Wine Division & Order Entry Divisions 322 70th Street, S. E. Charleston WV 25304 “AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER” http://www.wvabca.com FAX (304) 558-5599 American LegalNet, Inc. www.FormsWorkflow.com Form ABCC-WS-181 rev. 04/2007 Acceptable forms of payment of license fee is: Cashier’s Check, Certified Check Money Order or Company Check Licensing Period: ____________ to __________ License Number_________________________ West Virginia Alcohol Beverage Control Administration 322 70th Street, SE Charleston, WV 25304-2900 (304) 558-2481 Application for Representative’s License “ Distillery/Wine Supplier Representative “ Wine Distributor Representative Answer Questions 1-30 License Fee: $100.00 Answer Questions 1-25 License Fee: $00.00 1. Representative Name:_________________________________ 7. Company Representing:________________________________ 2. Rep’s Resident Address:________________________________ 8. Company’s FEIN:______________________________________ ____________________________________________________ 9. Business Physical Address:______________________________ City State Zip ____________________________________________________ 3. Rep’s Telephone:______________________________________ City 4. Date of Birth:_________________________________________ 10. Business Mailing Address:_______________________________ 5. Social Security Number:________________________________ Rep’s Email:________________________________________ 11. 12. Contact Person:__________________________________ Zip ____________________________________________________ City 6. State State Zip Business Telephone:___________________________________ Telephone Number:______________________________ 13. Has applicant or any officer been: a. Convicted of a felony? Yes________When:_____________________ If yes, attach sheet to explain. b. Convicted of a violation of federal or state alcohol laws? Yes____ If yes, attach sheet to explain. c. Convicted of a criminal offense (misdemeanor) within the last 5 years? Yes____ If yes, attach sheet. d. Refused any type of alcohol license or permit in any state? Yes____ State:____ If yes, attach sheet. No____ No____ No____ No____ 14. Has applicant or any officer had: a. A hearing before the WVABCA Commissioner? Yes___ Explain:________________________________ No____ b. Any type of WVABCA license or permit sanctioned? Yes___ Explain:____________________________ No____ 15. Has applicant been refused any type of alcohol license or permit in any state? Yes ___ Explain:___________ No____ 16. Does applicant or any blood relative own any real estate, buildings or equipment used by any WV wine retail licensee? Yes____ Attach a written explanation and give name, address and interest. 17. Does applicant or any blood relative hold any interest in a licensed wine retailer in West Virginia? Yes____ If yes, attach a written explanation and give name, address and interest. No____ No____ 18. Is the applicant, spouse of the applicant, or any blood relative a member of the West Virginia Alcohol Beverage Control Administration? Yes_______ Attach a written explanation of person and relationship. No____ 19. Is the applicant, spouse of the applicant, or any blood relative an elected or appointed state, county or municipal official? Yes _____ If yes, attach a written explanation of person, relationship, and office held. No____ 20. Is the applicant, or spouse of applicant, a member or officer of any political party executive committee of West Virginia? Yes _____ If yes, attach a written explanation. No____ 21. Has the applicant, during the fiscal year next preceding that for which this license is sought, made or given, voluntarily or on request, a gift, contribution or money or property to a member or an employee of the Commissioner, or to any West Virginia licensed wine distributor, or to or for the benefit of any political party committee or campaign fund? Yes____ If yes, how much $_________ to whom:_________________ No____ 22. Is applicant a salaried employee of the company to be represented? Yes____ No____ American LegalNet, Inc. www.FormsWorkflow.com 23. Will applicant receive any hidden benefits or bonuses in addition to the salary promised? Yes ____ No____ 24. What is applicant’s present employment or what has recently been applicant’s employment, craft, calling business or profession?____________________________________________________________________ 25. Does applicant contemplate continuing employment or business connections in addition to that for which this application serves? Yes____ No____ 26. Will applicant represent wine to West Virginia licensed wine distributors? No____ Yes____ 27. The monetary total of all wine sales made by the applicant to West Virginia licensed wine distributors during the fiscal year next preceding that for which this license is sought was $_______________. If not a full year, state portion thereof:_________________________________. 28. Will applicant represent liquor products? Yes____ No____ 29. The monetary total of all alcoholic liquor sales made by the applicant to the Commissioner during the fiscal year next preceding that for which this license is sought was $_______________. If not a full year, state portion thereof:_________________________________. 30. The monetary total of the gross income received by the applicant on the aforesaid liquor/wine sales was $_____________. Should the applicant fail to fully carry out and fulfill in every respect the laws of West Virginia, then the Commissioner shall have the right to terminate or revoke this license or permit and declare forfeited the penalty of the bond (if a bond is required for the selected license type). However, it is agreed and understood by and between the parties hereto that before such bond shall be forfeited a hearing shall be held in the Office of the West Virginia Alcohol Beverage Control Commissioner in the City of Charleston, Kanawha County, West Virginia, after ten (10) days written notice to the applicant, setting forth the charge or charges and the time and place of hearing thereon and which said notice shall be served the applicant by registered mail at the address hereinabove set forth. __________________________________________________________________________________ Signature of Sales Representative STATE OF ___________________, COUNTY OF__________________, to wit: Given under my hand and official seal this_____day of____________________,______. ______________________________________________________________________ Signature of Notary Public Commission Expires Seal of Notary TO BE COMPLETED BY THE OWNER, AN OFFICER, DIRECTOR, OR MANAGER OF THE COMPANY LISTED IN QUESTION #6. I affirm that the above named applicant is an authorized representative of this company and will be employed by this company if the requested license is issued. I agree to notify the Commissioner, in writing, if the above named applicant ceases to represent our company. Name of Company:_______________________________________________________________________________________________ _____________________________________________________________________________________________________________ Signature Title STATE OF ___________________, COUNTY OF__________________, to wit: Given under my hand and official seal this_____day of___________________,______. _____________________________________________________________________ Signature of Notary Public Commission Expires Seal of Notary American LegalNet, Inc. www.FormsWorkflow.com