Form Abl-107 - Application For Producer Of Alcoholic Liquor Certificate Of Registration July 2003 Page 4
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4STATE OF SOUTH CAROLINA
ABL-107-B
DEPARTMENT OF REVENUE
APPLICATION FOR CERTIFICATE OF REGISTRATION
(Rev. 7/29/03)
OF PRODUCER REPRESENTATIVE
4290
Mail to: SC Department of Revenue, ABL Section,
For Office Use Only
Columbia, SC 29214-0904.
File Number
License Period Ending
DLN
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 undersigned does hereby make
application for a Certificate of Registration as the South Carolina representative of the following Registered Producer:
Registered producer and address:
and for that purpose submit the following information:
1. Name:
Social Security Number:
2. Home Address:
Zip Code:
3. Business Address:
Zip Code:
4. Are you a resident of South Carolina?
How long?
Must be a resident of South Carolina for 30 days prior to applying.
5. Do you have a direct of indirect interest in a wholesale or retail liquor business in South Carolina?
Yes
No
6. Telephone number where you can be reached during business hours:
7. Fee - $250.00 (must be submitted with this application)
8. I do hereby certify that the SC Department of Revenue shall have the right within statutory limitations to audit and
examine the books and records, papers, and memoranda of the applicant, with respect to the administration and
enforcement of laws administered by the SC Department of Revenue and the South Carolina Law Enforcement Division.
STATE OF SOUTH CAROLINA
COUNTY OF
PERSONALLY appeared
who being duly sworn says: that the information given above is
true and correct to the best of his knowledge and belief.
Sworn and subscribed before me this
(Applicant Sign Here)
day of
,
(enter year)
APPROVED BY
Date
CERTIFICATE ISSUED:
YES
NO
Date
42901017
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