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Form Abl-107 - Application For Producer Of Alcoholic Liquor Certificate Of Registration July 2003 Page 2

(Name of individual applying)

Title

of the firm of

herby certify that the information contained in this application and the attached ABL-107A and ABL-107B is true and

correct to the best of my knowledge and belief. The Department of Revenue shall have the right within the Statutory

limitations to audit and examine the books and records, papers and memoranda of this form with respect to the

administration and enforcement of laws administered by the SC Department of Revenue and the South Carolina Law

Enforcement Division.

Signature of individual applying

Social Security Privacy Act Disclosure

It is mandatory that you provide your social security number on this form. 42 U.S.C 405(c)(2)(C)(i) permits a state to use

an individual's social security number as means of identification in administration. SC Regulation 117-1 mandates that

any person required to make a return to the SC Department of Revenue shall provide identifying numbers, as prescribed,

for securing proper identification. Your social security number is used for identification purposes.

42642017

Form Abl-107 - Application For Producer Of Alcoholic Liquor Certificate Of Registration July 2003 Page 2