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Form Abl-107 - Application For Producer Of Alcoholic Liquor Certificate Of Registration July 2003 Page 3

STATE OF SOUTH CAROLINA

ABL-107-A

DEPARTMENT OF REVENUE

APPLICATION FOR REGISTRATION OF

(Rev. 7/29/03)

BRANDS/WHOLESALERS OF ALCOHOLIC LIQUORS

4290

For Office Use Only

Mail to: SC Department of Revenue, ABL Section,

Columbia, SC 29214-0904.

File Number

License Period Ending

DLN

Amount Paid

14-3951-0006

SLED

34-3973-9000

In accordance with Chapter 7, Title 61, Code of Laws for SC, 1976, as amended, the Registered Producer noted below

does hereby make application to register the following brands of alcoholic liquors for shipment into the State of South

Carolina.

Registered producer address:

List certificate No.:

or check if application for certificate pending (

(

)

Contact person:

Telephone

INSTRUCTIONS: You must list all brands you intend to ship and the wholesaler you ship to. If additional space is

needed, this form may be reproduced. Please attach copy of Federal ATF approval for each brand listed.

Brand Name (list full brand name)

Proof

Age

Wholesaler

FEES: There is no fee for the first five (5) brands registered. The fee for each additional brand over five is $20.00 per

brand.

Total fees submitted:

Department of Revenue Use Only (Do not write in this space)

Brands approved by:

Date:

42881010

Form Abl-107 - Application For Producer Of Alcoholic Liquor Certificate Of Registration July 2003 Page 3