WLD-35 (9/15) WLD OFFICE USE 6601 Campstool Road, Cheyenne, Wyoming 82002-0110 Phone: (307) 777-7231 Fax: (307) 777-6255 Website: http://eliquor.wyoming.gov TERRITORY ASSIGNMENT OF WHOLESALER This assignment supersedes previous territorial assignment. Wholesaler:________________________________ Processed by:______________________________ Date Processed:___________________________ Please prepare a separate statement for each wholesaler representing your Brands in the state of Wyoming. In accordance with Section 12-2-201(b) of the Wyoming Statutes, the undersigned supplier representative certifies that the malt beverage wholesaler listed below is authorized to distribute brands shown in the designated geographical area. Suppliers include: Breweries, Microbreweries, Importers, Wholesalers and Distributors. Name of Supplier: Address: Telephone Number:( Wholesaler Assigned: ) City: Contact Name: Doing Business As: Doing Business As: State: Zip: DATE ASSIGNED BRANDS MARKETED (List the names of each malt beverage assigned) GEOGRAPHICAL TERRITORY / DISTRIBUTION AREA (List the Counties, Cities, or Towns in which Brands will be distributed) As a representative of the supplier named above, I verify that the foregoing information is true to the best of my knowledge and represents a true statement of the distribution areas for our products in the state of Wyoming. Printed Name Title: Signature: Phone: ( ) FAX: ( Date: _____/_____/______ ) American LegalNet, Inc. www.FormsWorkFlow.com