Application For And Certification/exemption Of Label/bottle Approval

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OMB No. 1512-0092 (06/30/2004)
DEPARTMENT OF THE TREASURY
FOR ATF USE ONLY
BUREAU OF ALCOHOL, TOBACCO AND FIREARMS
ID
APPLICATION FOR AND CERTIFICATION/EXEMPTION OF
CT
LABEL/BOTTLE APPROVAL
OR
AP
(See Instructions and Paperwork Reduction Act Notice on Back)
PART I - APPLICATION
7. NAME AND ADDRESS OF APPLICANT AS SHOWN ON PLANT REGISTRY, BASIC
1. VENDOR CODE
2.. SERIAL NUMBER
(Required)
(Required)
PERMIT OR BREWER'S NOTICE (Required)
YEAR
3. BRAND NAME (Required)
4. CLASS AND TYPE (Required) (Includes wine varietal
designation, if applicable)
7a. MAILING ADDRESS, IF DIFFERENT
5. FANCIFUL NAME (If any)
6. PLANT REGISTRY/BASIC PERMIT NO./BREWER'S NO.
(Required)
10. NET CONTENTS
16.
TYPE OF APPLICATION (Check applicable box)
8. FORMULA NO. (If any)
9. LAB. NO./DATE
11. PHONE NUMBER
a.
CERTIFICATE OF LABEL APPROVAL
(
)
b.
CERTIFICATE OF EXEMPTION FROM LABEL APPROVAL “For sale in
12. AGE (Distilled Spirits)
13. ALCOHOL
15.FAX NUMBER
14.VINTAGE (Wine products
_________ only” (Fill in State abbreviation)
CONTENT
only, if stated on label)
DISTINCTIVE LIQUOR BOTTLE APPROVAL. TOTAL BOTTLE CAPACITY
c.
(
)
BEFORE CLOSURE __________ (Fill in amount)
17.
SHOW ANY WORDING (a) APPEARING ON MATERIALS FIRMLY AFFIXED TO THE CONTAINER (e.g., caps, celoseals, corks, etc.) OTHER THAN THE LABELS AFFIXED BELOW, OR (b) EMBOSSED ON
THE CONTAINER. THIS WORDING MUST BE NOTED HERE EVEN IF IT DUPLICATES PORTIONS OF THE LABELS AFFIXED BELOW. ALSO, PROVIDE TRANSLATIONS OF FOREIGN LANGUAGE TEXT
APPEARING ON LABELS.
PART II - APPLICANT'S CERTIFICATION
Under the penalties of perjury, I declare: that all statements appearing on this application are true and correct to the best of my knowledge and belief;
and, that the representations on the labels attached to this form, including supplemental documents, truly and correctly represent the content of the
containers to which these labels will be applied. I also certify that I have read, understood and complied with the conditions and instructions which
appear on the reverse of an original ATF F 5100.31, Certificate/Exemption of Label/Bottle Approval.
18. DATE OF APPLICATION 19. SIGNATURE OF APPLICANT OR AUTHORIZED AGENT
20. TYPE NAME OF APPLICANT OR AUTHORIZED AGENT
PART III - ATF CERTIFICATE
This certificate is issued subject to applicable laws, regulations and conditions as set forth on the back of this form.
21. DATE ISSUED
22. AUTHORIZED SIGNATURE, BUREAU OF ALCOHOL, TOBACCO AND FIREARMS
FOR ATF USE ONLY
QUALIFICATIONS
EXPIRATION DATE (If any)
AFFIX COMPLETE SET OF LABELS BELOW
ATF F 5100.31 (4-98) PREVIOUS EDITION IS OBSOLETE

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