Form Ttb F 5100.18 - Application For Amended Basic Permit Under The Federal Alcohol Administration Act 2010

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OMB No. 1513-0019 (08/31/2011)
DEPARTMENT OF THE TREASURY
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU (TTB)
APPLICATION FOR AMENDED BASIC PERMIT UNDER THE FEDERAL ALCOHOL ADMINISTRATION ACT
(See instructions after this page)
1. NAME OF PERMITTEE
2. PERMIT NUMBER(S) TO BE AMENDED
3. EMPLOYER IDENTIFICATION NUMBER
REASON FOR CHANGE
CHANGE OPERATIONS ON PERMIT TO
5.
CHANGE
4.
CHANGE
OPERA-
NAME ON
T IONS
PERMIT
ADD NEW TRADE NAME(S) (State the purpose for which each trade name will be used. Use of trade name as a brand name on a label
6.
requires additional approval on TTB F 5100.31.)
CHANGE
IN TRADE
NAME(S)
REMOVE TRADE NAME(S)
CHANGE PREMISES ADDRESS TO (Number, street, route, city or town, State, and ZIP Code)
7.
CHANGE
ADDRESS
CHANGE MAILING ADDRESS TO (Number, street, route, city or town, State, and ZIP Code OR P.O. Box, city or town, State, and ZIP Code)
( ES)
8.
REMOVE
NAME
CHANGE IN
ADD THE FOLLOWING INDIVIDUAL (Attach separate sheet if adding more than one person)
OFFICER,
DIRECTOR,
a. FULL GIVEN NAME (no initials)
b. OTHER NAMES USED (include maiden and married)
c.
STOCK-
MALE
FEMALE
HOLDER
OR
e. BIRTH DATE
f. PLACE OF BIRTH
d. SOCIAL SECURITY NUMBER OR EMPLOYER
INVESTOR
(See
IDENTIFICATION NUMBER
instruction
1)
g. ARE YOU A U.S. CITIZEN?
h. NUMBER AND TYPE OF SHARES HELD if person holds more
than 10 percent.
YES
NO
i. TITLE WITH APPLICANT'S BUSINESS
j.
INVESTMENT IN PERMITTEE’S BUSINESS if more than 10
percent of capital.
(1) NEW
(2) SOURCE OF FUNDS (examples, savings,
k. RESIDENCES OR PRINCIPAL PLACES OF BUSINESS
loan, gift).
DURING THE PAST 5 YEARS
$
l.
HAS THIS PERSON EVER BEEN ARRESTED FOR, CHARGED WITH, OR CONVICTED OF, ANY CRIME UNDER FEDERAL,
STATE, OR FOREIGN LAWS other than misdemeanor traffic violations or convictions that are not felonies under Federal or State
law?
YES State details of each event on a separate sheet.
(State details of each event on a separate sheet.)
NO
m. HAS THIS PERSON EVER BEEN DENIED A PERMIT, LICENSE OR OTHER AUTHORIZATION TO ENGAGE IN ANY BUSINESS TO
MANUFACTURE, DISTRIBUTE, IMPORT, SELL, OR USE ALCOHOL PRODUCTS (beverage or nonbeverage) BY ANY GOVERNMENT
(Federal, State, local , or foreign) AGENCY OR HAD SUCH PERMIT, LICENSE, OR OTHER AUTHORIZATION REVOKED, SUSPENDED
OR OTHERWISE TERMINATED?
YES (State the details on a separate sheet.)
NO
9. ADDITIONAL INFORMATION. TTB may require additional evidence necessary to verify this application.
10. PERMITTEE’S AFFIRMATION Under penalties of perjury, I declare that I have examined this application, including accompanying statements, and
to the best of my knowledge and belief, it is true, correct, and complete. The business for which this permit is granted does not violate the law of the
State in which business will be conducted.
13. TELEPHONE NO.
11. SIGNATURE OF AUTHORIZED INDIVIDUAL
12. TITLE
14. DATE
15. E-MAIL (INTERNET) ADDRESS (optional) :
FOR TTB USE ONLY
16. SIGNATURE AND TITLE OF TTB OFFICIAL
17. DATE
TTB F 5100.18 (
/2010)

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