West Virginia Alcohol Beverage Control Administration 322 70th Street SE, Charleston, WV 25304 304-558-2481 Instructions for Completing Non-Retail Nonintoxicating Beer License Application Please read all instructions carefully and answer all questions completely. Your accuracy and thoroughness in completing the application submission will assist us in processing your application and prevent unnecessary delays. 1. Check appropriate boxes that apply to your submission. 2. Answer all questions and sections thoroughly that apply to the type of license you are applying for. 3. Application must be signed and notarized. Please follow the instructions for signature process. 4. Any yes answer to questions 9-12 requires a written statement attachment. 5. Bonds in the following amounts are required for licensure and must be properly executed. Continuation Certificates with Power of Attorney attached will be accepted in lieu of a new bond of renewal submissions only Brewer/Importer Bond: Resident Brewer/Importer Bond: Brewer Representative Bond: 25,000 Brew Pub Bond: 5,000 5,000 Distributor Bond: 1,000 500 6. Certified copy of Certificate of Authority to transact business in the State of West Virginia is required; new submissions only. You may contact the West Virginia Secretary of State’s Office for instructions on obtaining such. 304-558-8000. 7. Compliance with the WV Tax Department is required. You may contact the Tax Department at 304-558-0678, 5580689, 558-8695, 558-1114 for further information. 8. All new submissions applying as a corporation, limited liability company, and/or association must submit certified copies of such documents filed with the state in which that entity was formed. 9. License’s are effective July 1st to June 30th with exception of Brewer Representative Permits; October 1st to September 30th. 10. License fees must be paid by certified check, cashier’s check or money order. License fees are duly noted in the box for licensure. License fees are prorated semiannually for new submissions after December 31st, excluding Brewer Represent Permits. 11. Submissions for Brew Pub licensure require additional forms—floor plan, zoning, distance form, and background check. The back ground checks are completed using “Live Scan” and are twenty-four dollars ($24.00) per person. Instructions for the “Live Scan” will be mailed to you upon receipt of the required fee(s). Mail completed application, fee, bond and other requested /required documents to the address listed above. American LegalNet, Inc. www.FormsWorkFlow.com ABCA-MUD-BEERAPP Revised 03/2011 Licensing Period _______________ to _______________ License Number: ________________________________ Acceptable forms of payment for license fee: >Certified Check >Cashier’s Check >Money Order West Virginia Alcohol Beverage Control Administration 322 70th Street, S.E., Charleston, WV 25304-2900 (304)558-2481 Non-Retail Nonintoxicating Beer License Application Brewer/Importer License Brewer Representative Permit Distributor License Answer Questions 1-12 Answer Questions 1-6 & 8-12 Answer Questions 1-12 Individual Ltd. Liability Complete Section I Complete Section II Complete Section III Partnership Corporation License Fee: $1,500.00 License Fee: $50.00 License Fee: $1,000.00 Ltd. Partnership Association Applying As: 1. Licensee (Entity): 4. Business FEIN: 2. Business Name: 5. Business Telephone: 3. Mailing Address: 6. Physical Address: City State Zip City State Zip 7. Supply the following information about owners, officers, directors, members and/or managers. Title Name Date of Birth Resident Address Social Security Number Title Telephone Number Name Date of Birth Telephone Number Name Date of Birth % Ownership Resident Address Social Security Number Title Yrs. WV Residency Yrs. WV Residency % Ownership Resident Address Social Security Number Telephone Number *US Citizen *US Citizen Yrs. WV Residency % Ownership *US Citizen *Use a separate sheet if necessary. **If not a US Citizen, please attach a written explanation of when and where naturalized. 8. Contact Person: Telephone Number: E-Mail: If questions 9-12 are answered yes, a written statement must be attached to the application for license. 9. Has the applicant or any officer been convicted of: A) Felony? B) Violation of Federal or State Alcohol Laws? C) Criminal Offense (misdemeanor) within the last years? 10. Has applicant been refused any type of alcohol license or permit in any state? 11. Has applicant or any officer had: A) A hearing before the WVABCA Commissioner? B) Any type of WVABCA license or permit sanctioned? 12. Does the applicant, officers, directors or any blood relative own any of the following used by any retail licensee: A) Real estate? B) Buildings? C) Equipment? American LegalNet, Inc. www.FormsWorkFlow.com Section I Date and State Incorporated:_______________________________________________________________________________________________________ Date qualified to transact business in West Virginia:____________________________________________________________________________________ *Please include copies of corporate charter/articles, and/or organization papers along with copies of certificate of authority filed with the West Virginia Secretary of State Office; This applies to all entitles formed outside this state. Section II Name of Brewer/Importer employed by:______________________________________________________________________________________________ Address of employer:_____________________________________________________________________________________________________________ Telephone Number (Brewer):__________________________________________ Telephone Number (Applicant):________________________________________ Affix Picture Here E-mail of applicant: _________________________________________________ Date of current employment: __________________________________________ Social Security Number:______________________________________________ Picture not required for renewal submissions Date of Birth: ______________________________________________________ Resident (Applicant) Address: _____________________________________________________________________________________________________ Have you ever had a license with any other licensed Brewer/Importer? If yes, name and address of such: _________________________________________ Section III County within West Virginia distributorship located: ___________________________________________________________________________________ Date and State your business incorporated or organized:_________________________________________________________________________________ *Please include copies of corporate charter/articles, and/or organization papers along with copies of certificate of authority filed with the West Virginia Secretary of State Office; This applies to all entitles formed outside this state. Does applicant hold a valid lease?____________________________ Expiration date of lease: __________________________________________________ Property owner name/address:_____________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ Do the premises conform to all health, fire and zoning regulations?________________________________________________________________________ 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. Instructions for signing application: 1) Partnership/Limited Partnership: Must be signed by all partners; 2) Ltd. Liability Company: Must be signed by member (s); 3) Association: Must be signed by all members; 4) Corporation: Must be signed by an officer in the corporation; 5) Individual: Signature of that individual; 6) *Representatives must sign on their own behalf Signature(s), Title(s) of applicant(s) thereunto duly authorized State of: _______________________________________________________ County of:__________________________________________________________ Subscribed and sworn to before me this ____________________ day of __________________________________________, _____________________________. (Notary Public)_____________________________________________________________________________________________________________________ My commission expires the ________________________ day of _____________________________________________, _______________________________. American LegalNet, Inc. www.FormsWorkFlow.com Nonintoxicating Brewer’s Representative Bond (Revised 03/2011) West Virginia Alcohol Beverage Control Administration Brewer/’s Representative Bond October 1,_______________to September 30,_______________ Bond Number:_________________________________ Known All Men By These Presents: That I, ____________________________________________________ An Employee Of:______________________________________________ (Name of Brewer Representative) (Brewer) __________________________________________________________ ___________________________________________________________ (Address of Representative) (Address of Employer (Brewer)) As principal, and _____________________________________________________________, a corporation authorized to do business in the State (Surety Company) of West Virginia, as surety, are firmly bound unto the State of West Virginia in the just and full sum of FIVE HUNDRED DOLLARS ($500.00), to the payment whereof well and truly to be made, we bind ourselves, our successors and assigns, jointly and severally, firmly by these presents. This bond to run concurrent with the Brewer’s Representative Permit. WHEREAS, the condition of the above obligation is such that the above bound principal is about to obtain, in pursuance of the provisions of Chapter 11, Article 16 of the Code of West Virginia, as amended, and the Regulations promulgated by the Commissioner, a Brewer’s Representative Permit from the WEST VIRGINIA ALCOHOL BEVERAGE CONTROL COMMISSIONER, authorized representative of brewer or importer authorized to ship and/or sell beer and other malt beverages to West Virginia licensed distributors, as provided by Chapter 11, Article 16, of the Code of West Virginia as amended, and the Regulations promulgated by the WEST VIRGINIA ALCOHOL BEVERAGE CONTROL COMMISSIONER, then this obligation is void; otherwise this obligation shall remain in full force and effect, and I the license of the principal shall be revoked, then the full amount of this bond shall be forfeited to the State of West Virginia, and the full amount, when received by the State, shall be credited to the State’s General Revenue Fund. This bond is executed in pursuance of the provisions of said Chapter 11, Article 16 of the Code of West Virginia, as amended, and pertinent provisions of Article and Regulations promulgated by the WEST VIRGINIA ALOCHOL BEVERAGE CONTROL COMMISSIONER are made a part of this bond. IN WITNESS WHEREOF, the principal and the surely have caused their corporate names to be signed and affixed by their officials or agents duly authorized, and this bond is dated as of _____________day of _________________________________________, ________________. Principal: _______________________________________________ (Name of Brewer Representative) Surety: ________________________________________________ (Name of Surety Company) By:___________________________________________________ (Signature of Representative) By:___________________________________________________ (Signature and Title) Embossed Corporate Seal American LegalNet, Inc. www.FormsWorkFlow.com BREWER’S REPRESENTATIVE BOND INDIVIDUAL ACKNOWLEDGEMENT (To be completed by principal) STATE OF:_______________________________________________ To-Wit: COUNTY OF:___________________________________________________ I, ________________________________________________ a Notary Public in and for the county and state aforesaid, do hereby certify that ___________________________________________________, who signed the writing hereto annexed, for_______________________________, a __________________________________________________, bearing date on the __________ day of _________________________, ________, has this day in my said county, before me, acknowledged the said writing to be the act and deed of said individual. GIVEN under my had and official seal this __________ day of ____________________, __________. _____________________________________________________ (Notary Public) My commission expires the __________, day of ____________________, __________. CORPORATE ACKNOWLEDGEMENT (To be completed by Surety Company) STATE OF:_______________________________________________ To-Wit: COUNTY OF:___________________________________________________ I, ________________________________________________ a Notary Public in and for the county and state aforesaid, do hereby certify that ___________________________________________________, who signed the writing hereto annexed, for_______________________________, a __________________________________________________, bearing date on the __________ day of _________________________, ________, has this day in my said county, before me, acknowledged the said writing to be the act and deed of said corporation. GIVEN under my had and official seal this __________ day of ____________________, __________. _____________________________________________________ (Notary Public) My commission expires the __________, day of ____________________, __________. Approved as to sufficiency of form and manner of execution this __________ day of ____________________, __________. __________________________________________________________ By:________________________________________________________ Attorney General of the State of West Virginia (Assistant) American LegalNet, Inc. www.FormsWorkFlow.com