WLD-33 (4/18) 6601 Campstool Road Cheyenne, Wyoming 82002 - 0110 Wholesale Malt Beverage License Application License fee: $250.00 LICENSING TERM: From: to 9/20/2019 License #: Applicant: D/B/A : Premise Address: City: State: Zip: Mailing Address: City: State: Zip: Business Phone: Business Fax: Contact Person: Address of any satellite warehouses: FILING AS (CHOOSE ONLY ONE) I NDIVIDUAL (SOLE PROPRIATOR) CORPORATION LLC LLP 1. Is the licensed premises: Owned Leased Rented (A) If the premises is leased, please provide a copy of the lease. 2. Is this business a new enterprise? YES NO (If acquired from holder of Wyoming Wholesale Malt Beverage License and a basic permit under Federal Alcohol Administration A ct, complete items A through C.) (A) Name and address of license holder from whom business acquired: (B) Date of change in ownership or stock control: (C) Date business to be acquired by applicant: 3. Does applicant, either directly or indirectly, have actual or legal control over any other corporation or LLC , or is the business actually or legally controlled by any other corporation or LLC, whether such control is effected through stock ownership or in any other manner? YES NO (A) If yes, state the extent and manner of such control, the nature of the business, and the name and address of such corporation(s) or LLC(s) together wit h the names and addresses of the officers and directors of each such corporation or LLC. / / $ Cash Recpt #: Check Ck #: Processed by: Payment Processed: / / Control Number: American LegalNet, Inc. www.FormsWorkFlow.com WLD-33 (4/18) 4. List names of brewers or legally authorized agents, distributors or importers of malt beverages who have designated a geographic territory within which you may sell their malt beverage products to qualified liquor licensees or permitees. (If additional space is required, complete on a separate piece of paper and attach). Please att ach a completed Territorial Coverage form for each brewer / importer. BREWER/IMPORTER BRANDS TERRITORIAL COVERAGE DATE OF CERTIFICATION State law requires all malt beverage described above be available for purchase and delivery to all liquor licensees or malt beverage permittees within the territory designated. 5. If applicant is an Individual(s) or Partnership: State the name, date of birth and residence of the applicant and of each applicant or partner, if the application is made by more than one individual or partnership. True and Correct Name Date of Birth DO NOT LIST PO BOXES Residence Address, Street, City, State & Zip Residence Phone Number Have you been a DOMICILED resident for at least 1 year and not claimed residence in any other State in the last year? Do you hold any interest, directly or indirectly, in any liquo r license or permit issued in the State of Wyoming? Have you been Convicted of a Violation Relating to the sale or manufacture of Alcoholic Liquor or Malt Beverages? YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO (If more information is required, complete in identical form, on a separate piece of paper and attach to this application.) 6. If the applicant is a Corporation, Limited Liability Company, Limited Liability Partnership or Limited Partnership: State the name, date of birth and residence of each stockholder holding, either jointly or severally, ten percent (10%) or more of the outstanding and issued capital stock of the corporation, limited liability company, limited liability partnership, or limited partnership, and every officer, and every director. American LegalNet, Inc. www.FormsWorkFlow.com WLD-33 (4/18) True and Correct Name Date of Birth DO NOT LIST PO BOXES Residence Address, Street, City, State & Zip Residence Phone Number No of years in corp or LLC % of Stock Held Do you hold any interest, directly or indirectly, in any liquor license or permit issued in the State of Wyoming? Have you been Convicted of a Violation Relating to the sale or manufacture of Alcoholic Liquor or Malt Beverages? YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO (If more information is required, complete in identical form, on a separate piece of paper and attach to this application.) VERIFICATION AND ACKNOWLEDGEMENT By submission of this application, the applicant hereby agrees that: a) All applicable state and federal laws will be adhered to; b) All applicable state excise taxes will be timely reported and paid; c) Signature indicates that applicant has examined this application, including accompanying statement, and to the d) Requires all signatures for individual and partnership, 1 signature for an LLC and 2 signatures for corporations. STATE OF WYOMING ) SS. COUNTY OF ) Before Me, ,(specify) a Notary Public/Officer authorized to administer oaths in (Printed name of Notary or other officer authorized to administer oaths) and for County, State of Wyoming, Personally appeared (Insert Names) and he/she being first duly sworn by me upon his oath, says that the facts alleged in the foregoing instrument are true. (Seal) My commission expires: 1. 2. 3. 4. Witness my hand and official seal: Dated: (Notary public or other officer authorized to administer oaths) Please mail $250.00 check, application and (Title) a copy of your Federal Basic Permit to: Wyoming Liquor Division Compliance 6601 Campstool Rd. Cheyenne, WY 82002-0110 American LegalNet, Inc. www.FormsWorkFlow.com