Montana Form Avp-2 - Liquor Division Application For Vendors Permit - Department Of Revenue Page 2
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1
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3Statement of Representative
I have agreed to promote liquor products for __________________________________________________
and agree that the following information is true and correct.
Name ____________________________________________________
Home Address _________________________________________________________________________
Business Address ___________________________________________________ Phone _____________
Date of Birth _______________________ Place of Birth ________________________________________
Soc. Security No. ______________ Height _____ Weight _____ Color of hair _____ Color of eyes _____
Are you a Montana resident, qualified to vote in Montana, or hold a current Montana drivers license?
Yes ____ No ____
Have you ever been convicted of a misdemeanor or felony under the laws of the Federal Government or
any State of the United States? Yes _____ No ______
If yes, list office, date, court and place of conviction. ____________________________________________
______________________________________________________________________________________
Do you have direct or indirect financial interest in an alcoholic beverage retail license, beer wholesaler’s
license, table wine distributor’s license, state agency liquor store, brewery, or licensed winery?
Yes ____ No ____ If yes, please list name and address _______________________________________
______________________________________________________________________________________
I have read and understand the laws and rules of the State of Montana regarding the advertising and
promotion of alcoholic beverages and will abide by these laws and rules. Any statement found to be false or
misleading in any respect may constitute cause for denial or revocation of registration.
______________________________________
________________
Signature of Representative
Date
Statement of Representative
I have agreed to promote liquor products for __________________________________________________
and agree that the following information is true and correct.
Name ____________________________________________________
Home Address _________________________________________________________________________
Business Address ___________________________________________________ Phone _____________
Date of Birth _______________________ Place of Birth ________________________________________
Soc. Security No. ______________ Height _____ Weight _____ Color of hair _____ Color of eyes _____
Are you a Montana resident, qualified to vote in Montana, or hold a current Montana drivers license?
Yes ____ No ____
Have you ever been convicted of a misdemeanor or felony under the laws of the Federal Government or
any State of the United States? Yes _____ No ______
If yes, list office, date, court and place of conviction. ____________________________________________
______________________________________________________________________________________
Do you have direct or indirect financial interest in an alcoholic beverage retail license, beer wholesaler’s
license, table wine distributor’s license, state agency liquor store, brewery, or licensed winery?
Yes ____ No ____ If yes, please list name and address _______________________________________
______________________________________________________________________________________
I have read and understand the laws and rules of the State of Montana regarding the advertising and
promotion of alcoholic beverages and will abide by these laws and rules. Any statement found to be false or
misleading in any respect may constitute cause for denial or revocation of registration.
______________________________________
________________
Signature of Representative
Date
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