Form Alc 117 - Application For Certificate Of Registration For Manufacturers Of Alcoholic Beverages And High Alcohol Content Beer
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1
2TENNESSEE DEPARTMENT OF REVENUE
500 DEADERICK STREET
ANDREW JACKSON STATE OFFICE BUILDING
NASHVILLE, TN 37242
ALC
APPLICATION FOR CERTIFICATE OF REGISTRATION FOR MANUFACTURERS OF
117
ALCOHOLIC BEVERAGES AND HIGH ALCOHOL CONTENT BEER
BUSINESS NAME AND EXACT LOCATION
BUSINESS MAILING ADDRESS
Owner Name __________________________________
Trade Name ______________________________
Address 1 ____________________________________
Address 1 ________________________________
Address 2 ____________________________________
Address 2 ________________________________
City, State, Zip _________________________________
City, State, Zip ____________________________
Business Phone _______________________________
Is business located inside city limits? Yes ( ) No ( )
If "yes", specify city _________________________
Please complete this application and return it to this office with the appropriate remittance as shown on the bottom of this
notice. All questions must be answered completely for your application to be processed.
Any person failing to obtain a renewal certificate by July 1st of each year will be penalized 5% for each month or part of a
month the application is late, up to a maximum of 25% plus interest.
Applicants must complete the Application for Registration, which can be found on the Department's website at
Applicants must also complete the appropriate Brand Registration document to register or renew all products. Brand Regis-
tration documents can be found on the Department's website at
.
For additional information regarding this application you may call Taxpayer Services between 8:00 a.m. and 4:30 p.m. (CT),
Monday through Friday, holidays excepted. Please see the back of this notice for our local offices and phone numbers.
Type of Ownership: ( ) Proprietorship ( ) Partnership ( ) Corporation
SSN
FEIN
IDENTIFY OWNERS, OFFICERS, OR PARTNERS (if more space is required attach additional sheets).
(1) Name ___________________________________
(2) Name ________________________________
Address _________________________________
Address ______________________________
City, State, Zip Code _______________________
City, State, Zip Code ____________________
________________________________________
_____________________________________
Phone No. _______________________________
Phone No. ____________________________
Manufacturer Fee: ($1,000.00) _____________________
FOR OFFICE
USE ONLY
MAKE CHECK PAYABLE TO:
TENNESSEE DEPARTMENTOF REVENUE
Date of adoption from the county favoring the manufacture of intoxicating liquors:
Date of adoption from the municipality, if applicable, favoring the manufacture of intoxicating liquors:
Under penalties of perjury, I declare that the statements in this application are true and correct to the best of my knowledge and
belief. This application applies only to the specified business and location listed hereon.
Authorized Signature & Title
Date
RV-F1321601
INTERNET (06-13)
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