STATE OF WYOMING Department of Revenue Liquor Division 1520 E 5th Street Cheyenne, WY 82002-0110 (307) 777-7233 APPLICATION FOR OUT-OF-STATE SHIPPER LICENSE Applicant: D/B/A: Contact Person: Phone: ( ) - Company Location: City: State: Zip: Mailing Address: City: State: Zip: Business Phone: Business Fax: E-Mail Address: Website: FILING AS (CHOOSE ONLY ONE) SOLE PROPRIETOR PARTNERSHIP CORPORATION LLC LLP If a corporation, LLC or LLP list the full names and residence address of all the officers and directors and of all shareholders owning jointly or severally ten percent (10%) or more of the stock of the corporation, LLC or LLP. Use back of form if additional space is needed. NAME RESIDENCE ADDRESS DATE OF BIRTH % OF STOCK By filing this application, I agree to operate in Wyoming under the requirements of W.S.12-2-204 and all other applicable Wyoming laws and rules, and to file required monthly tax reporting documents and taxes. If no shipments occur for any given month, the monthly tax report is not required. I understand that violation of these laws and rules may constitute cause for denial, suspension or revocation of my license. Please attach to this application a copy of the current state license(s) under which you are operating. By signing this application, I acknowledge for __________________________________________(Business Name) that all of the information provided is true and correct, and that I agree to meet the Wyoming operating conditions specified above. This application must be signed by an owner, partner, corporate office or LLC/LLP member. Signature: ____________________________________ Date: / Title: ________________________________ / Mail completed application and a check for $50.00 made out to the Wyoming Liquor Division to: Wyoming Liquor Division Attn: Licensing 1520 E 5th St Cheyenne, WY 82002-0110 Rec'd application: Rec'd cash/check: Reviewed by: American LegalNet, Inc. www.FormsWorkflow.com