Form Sfn 22935 - Application For Alcoholic Beverage Manufacturing License Form - Office Of State Tax Commissioner

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APPLICATION FOR ALCOHOLIC BEVERAGE MANUFACTURING LICENSE

OFFICE OF STATE TAX COMMISSIONER

TAX TYPE 96

SFN 22935 (9-03)

FOR TAX DEPARTMENT USE ONLY

License Number

! New License

! License Renewal

Name of Applicant (business, partnership, corporation)

DBA or Trade Name

FEIN

Location of manufacturing business

Mailing Address

City

State

Zip Code

County

Telephone #

FAX #

E-Mail Address

Type of Business:

! Sole Proprietorship

! Partnership

! Corporation

! LLC

1. Type of alcoholic beverage manufacturing:

! Winery

! Distillery

! Brewery

Anticipated manufacturing capacity ______________________________________________________________________________

2. Do you have any financial interest in any wholesale or retail beer or liquor establishment? (If corporation, include all

! Yes

! No

officers, directors, and stockholders; if partnership, include all partners.)

If yes, list establishments ______________________________________________________________________________________

! Yes

! No

3. Have you ever had any type of license suspended or revoked in North Dakota or in any other state?

If yes, list where and when ____________________________________________________________________________________

4. List basic federal permit and other permit number and their effective dates

Permit type _________________________________________

Permit # ______________________

Effective date _______________________

Permit type _________________________________________

Permit # ______________________

Effective date _______________________

5. List names of North Dakota wholesalers who intend to sell your merchandise __________________________________________________________

6. North Dakota law provides that no foreign corporation or foreign limited liability company may conduct business in this state or obtain any license or

permit required by this state until it has procured a certificate of authority from the secretary of state. North Dakota law also provides that no foreign

limited partnership or foreign limited liability partnership may conduct business in the state until it has registered with the secretary of state.

(Questions regarding certificates of authority and registrations should be directed to the North Dakota Secretary of State at 701-328-4284.)

List the state in which your company is organized

________________________________________________________________________________________________________________________

Enter the ID number assigned to your business by the North Dakota Secretary of State or attach a copy of the Certificate of Authority.

________________________________________________________________________________________________________________________

First-time license fee = $500.00 (reduced to $375.00 for effective dates between April 1 and June 30, and reduced to $250.00 for effective dates

between July 1 and December 31).

Renewal Fee = $500.00 per calendar year.

I, the undersigned, hereby apply for the above indicated license for the calendar year ending December 31, ________. I understand that any misstatement

or concealment of fact in this application shall be grounds for revocation of the license.

____________________________________________________________

_______________________________

___________________________

Signature of Applicant

Title

Date

DO NOT WRITE IN THIS SPACE

Please send application and license fee to:

Office of State Tax Commissioner

Alcohol Tax Section

Phone: (701) 328-3139