Form 47-264-11-1-1-000 - Application For Registration Of Manufacturer'S Representatives Or Control State Manager - Department Of Revenue

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ALCOHOLIC BEVERAGE CONTROL
Form 47-264-11-1-1-000 (Rev. 11/13)
Mail this Application
TO:
Alcoholic Beverage Control
P.O. Box 540
Madison, Mississippi 39130-0540
APPLICATION FOR REGISTRATION OF MANUFACTURER’S REPRESENTATIVES
OR
CONTROL STATE MANAGER
Manufacturer’s Name:________________________________________________________________________
Address:___________________________________________________________________________________
Brands to be Marketed and Shipping Point(s) for Each Brand:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_______________________________________________________
Representative to be Registered: (Executive Officer or Control States Manager)
Name: ________________________________ Title:________________________________________________
Business Address and Telephone Number:________________________________________________________
__________________________________________________________________________________________
E-Mail Address _____________________________________________________________________________
Home Address and Telephone Number: __________________________________________________________
__________________________________________________________________________________________
Length of Time Employed by Manufacturer: ______________________________________________________
Previous Experience in Sales and Distribution of Alcoholic Beverages: __________________________________
_____________________________________________________________________________________________
__________________________________________________________________________________________
Extent of Authority to Commit to Contract on Behalf of Manufacturer: __________________________________
_____________________________________________________________________________________________
__________________________________________________________________________________________
We certify as manufacturer, distiller, distributor, rectifier, or importer, that our official representative named above
will, at all times, comply with the Laws, Rules and Regulations applicable to us as enforced and overseen by the
Mississippi Department of Revenue. We further certify that we have been informed of such Laws, Rules and
Regulations. Finally, the person signing this Application certifies under oath that all the information contained in
this document is true and correct and he or she has the authority to sign this document as the manufacturer or on
behalf of the manufacturer and acknowledges that this Application is being signed under the penalty of perjury
pursuant to Mississippi Code Annotated Section 27-3-83(5).
By:___________________________________________________________________________________
Name of Officer
Title
Date
P. O. Box 540
Madison, MS 39130
Phone: 601.856-1301
FAX: 601.856-1390

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