Form Sfn 22910 - Alcoholic Beverage Supplier License Application
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6ALCOHOLIC BEVERAGE SUPPLIER LICENSE APPLICATION
NORTH DAKOTA OFFICE OF STATE TAX COMMISSIONER
SFN 22910 (6-05)
(All information must be complete and accurate)
Before a supplier may engage in the sale or shipment of alcoholic beverages to a licensed North Dakota
wholesaler, that supplier must fi rst procure a supplier license from the state Tax Commissioner. This
requirement does not apply to North Dakota manufacturers, domestic wineries, microbrew pubs, or
wholesalers already licensed by the Tax Commissioner.
Business Information
Company Name
FEIN
DBA Name (if applicable)
FEIN
Mailing Address
City
State
Zip Code
Contact Person
Title of Contact Person
Telephone Number
Fax Number
E-mail Address
Physical Address of Headquarters
(if different from mailing address):
City
State
Zip Code
Telephone Number
Fax Number
Check the categories that apply to your business:
Ì Manufacurer
Ì Importer
Ì Marketer
Ì Wholesaler
I declare under the penalties of North Dakota Century Code § 12.1-11-02, which provides for a Class A
misdemeanor for making a false statement in a governmental matter, that this application has been examined
by me and to the best of my knowledge and belief is complete, correct, and true.
Name of Owner or Authorized Offi cer (print or type)
Title
Signature of Owner or Authorized Offi cer
Date
There are no fees for this license
For Tax Department Use Only
Please send application to:
Approved by: __________________________________
Date: ________________________________________
Alcohol Tax Section
Offi ce of State Tax Commissioner
License no.: __________________________________
600 E. Boulevard Ave., Dept. 127
Date issued: __________________________________
Bismarck, ND 58505-0599
Phone: (701) 328-2702
Date canceled: _________________________________
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Parent category: Financial