WLD-05 (05-05) DEPARTMENT OF REVENUE LIQUOR DIVISION NEW RENEWAL 1520 East 5th Street Cheyenne, WY 82002-0500 Rec'd application: Rec'd cash/check: Reviewed by: APPLICATION for Class “A” INDUSTRY REPRESENTATIVE LICENSE LICENSE TERM: July 1, 2005 through June 30, 2006 Applicant Residence Address City State Zip Mailing Address City State Zip Business Name Home Phone: 1. Are you 18 years of age or older? Yes 2. Are you domiciled in Wyoming? Yes Business Phone: No No 3. (a) Do you presently hold any interest (directly or indirectly) in any type of retail liquor license or retail malt beverage permit within the State of Wyoming? Yes No (b) If "Yes," please attach a full explanation. 4. (a) Have you been convicted of a felony or a violation of federal or state statutes relating to sale or manufacture of alcoholic beverages in the ten (10) years preceding this application? Yes No 5. Have you ever had a liquor or industry representative license denied, canceled, suspended or revoked? Yes If "Yes," please attach a full explanation. No 6. (a) List below all liquor, wine, or malt beverage manufacturers, wholesalers, rectifiers, importers, etc., which you will represent within the State of Wyoming. Describe your employment/contractual arrangements with each company, i.e., salaried, broker, commission, etc. Attach additional sheet if necessary. COMPANY ADDRESS EMPLOYMENT/CONTRACTUAL ARRANGEMENT (b) If application is for a NEW license, or you are adding companies, please attach written verification from each vendor of your employment or contractual relationship with them. The verification should include the vendor's request for you to be licensed to represent it's particular brand or brands in Wyoming. 7. I have read and understand the laws and rules of the State of Wyoming regarding the advertisement and promotion of alcoholic beverages and will abide by these laws and rules. I understand that violation of these laws and rules may constitute cause for denial, suspension or revocation of my license. _________________________________________________ _____________________ Signature Date ________________________ $100.00 FEE AND UPDATED VENDOR LIST IS DUE WITH APPLICATION LICENSE RENEWABLE ANNUALLY 45 DAYS PRIOR TO EXPIRATION DATE OF JUNE 30TH American LegalNet, Inc. www.FormsWorkflow.com