(304)3565560223ANEQUALOPPORTUNITY/AFFIRMATIVEACTIONEMPLOYER224Fax(304)9570311http://www.abca.wv.gov STATEOFWESTVIRGINIADEPARTMENTOFREVENUEALCOHOLBEVERAGECONTROLADMINISTRATION900PennsylvaniaAvenue,4thFloorCharleston,WestVirginia25302ThankyouforyourinterestinbecomingavendorofalcoholicspiritsforthestateofWestVirginia.WearehonoredthatyouhavechosenWestVirginiaaspartofyourfuturegrowth.Ourstaffiscommittedtoprovidingtheinformationandservicesrequiredforafaststart.ThemissionoftheAlcoholBeverageControlAdministrationistosellandcontroltheuseofalcoholicbeveragesandtoenforcethelawsandregulationsregardingalcoholicbeveragesintheStateofWestVirginia.Enclosedaretheapplicationsanddocumentsnecessaryforregistrationasavendorforalcoholicspirits.ItisourgoaltoprovideyouwiththeassistanceneededtocompletethisprocesstherebybringingyourproductstothemanyconsumersofWestVirginia.Again,thankyouforyourinterestandpleasedonothesitatetocontactourofficeforanyconcernsorquestionsyoumayhave.Wewelcometheopportunitytoworkwithyouandlookforwardtoachievingourgoalstogether. American LegalNet, Inc. www.FormsWorkFlow.com (304)3565500223ANEQUALOPPORTUNITY/AFFIRMATIVEACTIONEMPLOYER224Fax(304)9570311http://www.abca.wv.govSTATEOFWESTVIRGINIADEPARTMENTOFREVENUEALCOHOLBEVERAGECONTROLADMINISTRATION900PennsylvaniaAvenue4thFloorCharleston,WV25302ABCASTAFFCONTACTINFORMATION EdHartDistributionCenterManager(304)356.5571(DistributionCenter) Commissioner(304)3565500@wv.gov Edward.L.Hart@wv.gov KimCanterburyHayesJuliaJonesSpirits,Wine,&OrderEntryManagerAccountingDivisionManager (304)3565574(304)3565500,extension55837(304)9570327fax(304)9570302faxfax(304)9570311Julia.M.Jones@wv.gov Kimberly.D.Canterbury@wv.govContactfor:LiquorPayments,Bailment ABCC.Spirits@wv.govAuthorization,HoldHarmlessAgreements ABCC.Pricing@wv.govDebitMemorandums&ClaimsSupport ABCC.Wine@wv.gov ABCC.Orders@wv.gov Contactfor:BailmentInventory,Changes,BailmentShipmentApprovals,Sales&InventoryReports,SpiritPricing,Quotes&SpecialPriceAllowances,VendorRegistrationWineBrandRegistration,WineDistribution American LegalNet, Inc. www.FormsWorkFlow.com (304)3565500223ANEQUALOPPORTUNITY/AFFIRMATIVEACTIONEMPLOYER224Fax(304)9570311http://www.abca.wv.gov STATEOFWESTVIRGINIADEPARTMENTOFREVENUEALCOHOLBEVERAGECONTROLADMINISTRATION900PennsylvaniaAvenue4thFloorCharleston,WV25302Everyperson,company,orcorporationintendingtodobusinessinWestVirginiamustregisterwiththeWestVirginiaStateTaxDepartment.Additionally,corporations,limitedpartnershipsandlimitedliabilitycompaniesmustregisterwiththeWestVirginiaSecretaryofStateandobtaineitheraCertificateofAuthorityoranExemptiontoCertificateofAuthority.Pleaseconsultwiththeappropriateperson(s)inyourorganizationaboutcompliancewiththebusinessregistrationrequirementsinWestVirginia.Shouldfurtherassistancebenecessary,youmaycontactthefollowingsourcesforregistrationinformation:WestVirginiaSecretaryofStateBusinessDivisionCapitolComplex1900KanawhaBoulevardEastBuilding1,Room157KCharleston,WV25305(304)5588000Email:business@wvsos.com http://www.sos.wv.gov/businesslicensing/Pages/FormIndexforBusinessFilings.aspx WestVirginiaStateTaxDepartmentTaxpayerServicesDivisionP.O.Box3784Charleston,WV253373784(304)5583333or18009828297http://www.state.wv.us/taxrev/forms/2009/businessRegistration.booklet.pdf American LegalNet, Inc. www.FormsWorkFlow.com (304)3565500223ANEQUALOPPORTUNITY/AFFIRMATIVEACTIONEMPLOYER224Fax(304)9570311http://www.abca.wv.gov STATEOFWESTVIRGINIADEPARTMENTOFREVENUEALCOHOLBEVERAGECONTROLADMINISTRATION900PennsylvaniaAvenue4thFloorCharleston,WV25302ADDITIONALINFORMATION LIQUORVENDORSAREEXEMPTFROMTHE$125.00ANNUALFEETHATISREFERENCEDINTHEVENDORREGISTRATIONANDDISCLOSURESTATEMENT(FORMWV1A).PLEASERETURNALLCOMPLETEDVENDORREGISTRATIONPACKETSTO:WESTVIRGINIAALCOHOLBEVERAGECONTROLADMINISTRATIONATTENTION:SPIRITSDIVISION900PENNSYLVANIAAVENUE4thFLOORCHARLESTON,WV25302 American LegalNet, Inc. www.FormsWorkFlow.com WV-1A New Update REV. 09/26/18 STATE OF WEST VIRGINIA - PURCHASING DIVISION VENDOR REGISTRATION AND DISCLOSURE STATEMENT AND SMALL, WOMEN-, AND MINORITY-OWNED BUSINESS CERTIFICATION APPLICATION Beforeavendoriseligibletosellgoodsand/orservicestotheStateofWestVirginia,theWestVirginiaCode2475A312requiresallvendorstohaveonfilewiththeWestVirginiaPurchasingDivisionacompletedVendorRegistrationandDisclosureStatement.VendorssupplyingsolesourcegoodsorservicestoWestVirginiastateagencies,orcompetitivepurchasesof$2,500orlessannuallyinaggregateacrossallstateagenciesarerequiredtocompletetheVendorRegistrationandDisclosureStatement(WV1Aform).Iftheamountforcompetitivepurchasesexceed$2,500inaggregateacrossallstateagenciesinanyoneyear,a$125.00annualfeeisrequired.PaymentoftheannualfeeincludesemailnotificationsonbidopportunitiesbasedonthecommoditiesandservicesselecteduponregisteringintheVendorSelfService(VSS)portalatwvOASIS.gov.PleasecompletePartIofthisforminitsENTIRETYandreturntothestateagencylistedbelowfortheircompletionofPartII.TheagencywillforwardthisformtotheWestVirginiaPurchasingDivisionforprocessing.Incompleteformswillnotbeprocessedandwillbereturnedtothevendor.Pleasereturnallcorrespondenceto:STATEAGENCY:ADDRESS:CITY,STATE,ZIP:Wheneverachangeoccursintheinformationsubmitted,suchchangeshallbereportedimmediatelyinthesamemannerasrequiredintheoriginaldisclosurestatement(WestVirginiaCode2475A312).VendorsdoingbusinesswiththeStateofWestVirginiaareexpectedtoabidebytheVendorCodeofConductavailableonlineatwww.state.wv.us/admin/purchase/vrc/vendorconduct.pdf.PrivacyNotice:ThePurchasingDivisionisrequiredtocollectcertaininformationasstatedinWestVirginiaCode2475A312,otherapplicablesectionsoftheWestVirginiaCode,theVendorRegistrationandDisclosureStatementforms,andotherdocumentstofacilitatethestatebiddingandcontractadministrationprocesses.Thisinformationisstoredinasecureenvironment,butunlessspecificallyprotectedunderstatelaw,anyinformationprovidedmaybeinspectedbyordisclosedtothepublic.VendorsarealsorequiredtobelicensedandingoodstandinginaccordancewithanyandallstateandlocallawsandrequirementsbyanystateorlocalagencyofWestVirginia,including,butnotlimitedto,theWestVirginiaSecretaryofState222sOffice,theWestVirginiaTaxDepartment,WestVirginiaInsuranceCommission,orotherstateagenciesorpoliticalsubdivisions.Failuretodosomayresultindelayofordisqualificationfromacontractaward,pursuanttoWestVirginiaCodeofStateRules24714816.1.7.IfyouhaveanyquestionsconcerningthisVendorRegistrationandDisclosureStatement,pleasecontactthePurchasingDivisionat(304)5582311.QuestionsconcerningthisVendorRegistrationandDisclosureStatementmaybedirectedtothePurchasingDivisionat(304)5582311.Shouldyouneedadditionalinformationrelatingtovendorregistration,pleasevisitwww.state.wv.us/admin/purchase/VendorReg.html. American LegalNet, Inc. www.FormsWorkFlow.com VENDOR REGISTRATION AND DISCLOSURE STATEMENT AND SMALL, WOMEN-, AND MINORITY-OWNED BUSINESS CERTIFICATION APPLICATION PLEASE TYPE OR CLEARLY PRINT ALL INFORMATION To Be Completed by the Vendor and Returned to the Purchasing Division 1. LegalNameofCompany/Individual BiddingAddress OrderingAddress (Pleaseprovideaphysicaladdress,notapostofficebox.) PaymentAddress City,State,Zip TelephoneNumberFaxNumber PrincipleContactPersonEmail Contact222sTelephoneNumberContact222sFaxNumber DBA,ifany BiddingAddress OrderingAddress PaymentAddress City,State,Zip TelephoneNumberFaxNumber PrincipleContactPersonEmail Contact222sTelephoneNumberContact222sFaxNumber 2.VendorTaxClassification: Individual GovernmentSoleProprietor MedicalCorporationPartnership AttorneyCorporationCorporation NonProfitOrganization BoardMemberPayrollTrust EmployeeEstate American LegalNet, Inc. www.FormsWorkFlow.com VENDOR REGISTRATION AND DISCLOSURE STATEMENT AND SMALL, WOMEN-, AND MINORITY-OWNED BUSINESS CERTIFICATION APPLICATION PLEASE TYPE OR CLEARLY PRINT ALL INFORMATION To Be Completed by the Vendor and Returned to the Purchasing Division 3.TaxpayerIdentificationNumber(TIN):IfyouhaveanIdentificationNumber,enteritbelow.Allpartnerships,corporations,orcompanieswithemployeesmusthaveanEIN. EIN IfyoudonothaveaEIN,pleaseenterSocialSecuritynumber(SSN),IndividualTaxpayerIdentificationNumber(ITIN)orAdoptiveIdentificationNumber(ATIN)andcheckthecorrectbelow. - (SSN,ITIN,ATIN) 4.(A)Small,WomenOwned,MinorityOwnedB