Form 115(W) - Application For Permit To Conduct Wine Tasting Function Page 3
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3PERMIT
___________________________________________________, certifies that he/she is____________________________________________
(Title)
of the above named applicant corporation; that he/she knows the contents of the above application and the statements and answers therein; that
the same are true of his/her own knowledge; that he/she has been authorized, by order of the Board of Directors of said applicant corporation to
make the statements and answers in this application in behalf of said applicant corporation with the same force and effect as if said corporation
made such statements and answers itself.
Dated __________________________________________
________________________________________________________
( Signature of authorized officer)
Wine Tasting (revised 03/11)
Form 115 (w) miscellaneous
Completed applications and any supporting information should be mailed to:
NEW YORK STATE LIQUOR AUTHORITY
PO BOX 3796
NEW YORK, NY 10008-3796
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