Form Ttb F 5013.2 - Colas Online Access Request

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OMB No. 1513-0111 (05/31/2012)

ALFD TRACKING NUMBER

DEPARTMENT OF THE TREASURY

ALCOHOL AND TOBACCO TAX AND TRADE BUREAU (TTB)

COLAs ONLINE ACCESS REQUEST

Submit this form to the Advertising, Labeling and Formulation Division (ALFD), TTB, 1310 G Street, N.W., Suite 400E, Washington, DC 20220

A – ACTION REQUESTED - Please read instructions to check appropriate box

IF MODIFYING, DELETING, OR REACTIVATING

THEN PROVIDE EXISTING USER ID, if known

NEW USER

PREPARER/REVIEWER

MODIFY USER/

DELETE USER

REACTIVATE USER

ADD PERMIT

Please complete section B with all the required data to establish a user identification record.

B – USER INFORMATION:

3. FIRST NAME

4. MIDDLE

5. LAST NAME

6. SUFFIX

(i.e., Jr., Sr., III)

INITIAL

7. LABEL REP ID NUMBER, if any

8. DATE OF

MOTHER’S MAIDEN NAME

10. EMPLOYEE TITLE

BIRTH

11. BUSINESS PHONE NUMBER

12. BUSINESS E-MAIL ADDRESS (required)

13. BUSINESS FAX NUMBER

14. BUSINESS MAILING ADDRESS OF PERSON REQUESTING ACCESS TO COLAs ONLINE (if

different than 15.)

Provide information about the company for which you request to e-file applications

C – COMPANY INFORMATION:

15. NAME AND STREET ADDRESS OF COMPANY AS IT APPEARS ON THE REGISTRY, PERMIT, OR BREWER’S NOTICE

16. REGISTRY, PERMIT, OR BREWER’S NOTICE NUMBER(S) FOR THE ABOVE ADDRESS (Use a separate sheet if necessary. See instructions.)

REQUESTOR’S CERTIFICATION

I hereby attest that the entries on this form are true and correct, and that the unique username and password, or digital signature that the Alcohol and

Tobacco Tax and Trade Bureau assigned to me are intended as my original signature. I intend that such submissions be treated as bearing an

original signature for all intents and purposes when submitting applications electronically via COLAs Online system.

17. REQUESTOR’S SIGNATURE

18. DATE

D – APPROVAL REQUIRED: Signature of the company official with signature authority required to grant access to COLAs Online.

19. COMPANY APPROVAL SIGNATURE

20. PRINT NAME AND TITLE OF COMPANY APPROVAL OFFICIAL

21. DATE

FOR TTB USE ONLY

USER VERIFICATION COMPLETED

DATE

COMMENTS