Form Ltd 6 10-00 - Application For License For Importer And Wholesale Dealer Of Wine Liquor And Beer - Nevada Department Of Taxation, Carson City

Original To Board of County Commissioners

Form LTD 6 10-00

Copy to Nevada Department of Taxation, Carson City

APPLICATION FOR LICENSE FOR IMPORTER AND WHOLESALE DEALER

OF WINE, LIQUOR AND BEER

.............................................................................., 20 ............

Honorable Board of County Commissioners:

..............................................................................County, ................................................................, Nevada.

(City or Town)

In accordance with the provisions of NRS, Chapter 369, as amended, the undersigned hereby applies for a license for

....................................................................................................................................................................................

(Type of license(s) – see reverse side)

st

in the State of Nevada, for the fiscal year ending June 30, 20........ . A remittance covering the license fees from the 1

day

th

of.........................................., 20 ......... to the 30

day of June, 20......... is enclosed (not less than one quarter of a year).

The following information is also set forth:

(1) Name of form.........................................................................................................................................................

Doing business as...................................................................................................................................................

Located at..............................................................................................................................................................

(Number)

(Street)

(City)

(Zip)

Mailing address ................................................................................................ Phone............................................

(zip)

(2) The applicant is:

(a) A corporation? ..................... Organized under the laws of what state?.................................................................

When? .................................................Qualified to do business in Nevada?.............................................................

When? .................................................Names and addresses of following officers:

President................................................................................................................................................................

Vice President........................................................................................................................................................

Secretary................................................................................................................................................................

Treasurer ...............................................................................................................................................................

Manager or Managers.............................................................................................................................................

.............................................................................................................................................................................

Resident Agent.......................................................................................................................................................

(b) A partnership? ..................................................Is agreement recorded? .............................................................

Where?................................................................... . Names and addresses and official position, if any, of partners?

.............................................................................................................................................................................

.............................................................................................................................................................................

(c) Operating under a fictitious firm name?...............Is statement recorded? ....................Where?..............................

Names, addresses and official positions, if any, of all persons interested in the business:

.............................................................................................................................................................................

.............................................................................................................................................................................

(d) An individual? ...................................................

(e) Has any individual who is interested, financially or otherwise, in the applicant’s business, ever been convicted of a

violation of Federal or any state liquor laws?......................If so, furnish:

Name

Address

Where convicted

When

.......................................................................................................................................................................................................................................

.......................................................................................................................................................................................................................................

.......................................................................................................................................................................................................................................

OVER