Form Ttb F 5100.24 - Application For Basic Permit Under The Federal Alcohol Administration Act Page 2

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a. FULL GIVEN NAME

b. DATE AND PLA CE OF

c. SOCIAL SECURITY OR EMPLOYER

d. ARE YOU A U .S. CITIZEN?

BIRTH

IDENTIFICATION NUMBER

YES

f. OTHER NAMES USED (Maiden name, nicknames, etc.)

MALE

FEMALE

g. RESIDENCE(S) OVER THE LAST FIVE YEARS

a. FULL GIVEN NAME

b. DATE AND PLA CE OF

c. SOCIAL SECURITY OR EMPLO YER

d. ARE YOU A U .S. CITIZEN?

BIRTH

IDENTIFICATION NUMBER

YES

f. OTHER NAMES USED (Maiden name, nicknames, etc.)

MALE

FEMALE

g. RESIDENCE(S) OVER THE LAST FIVE YEARS

a. FULL GIVEN NAME

b. DATE AND PLA CE OF

c. SOCIAL SECURITY OR EMPLO YER

d. ARE YOU A U .S. CITIZEN?

BIRTH

IDENTIFICATION NUMBER

YES

f. OTHER NAMES USED (Maiden name, nicknames, etc.)

MALE

FEMALE

g. RESIDENCE(S) OVER THE LAST FIVE YEARS

a. FULL GIVEN NAME

b. DATE AND PLA CE OF

c. SOCIAL SECURITY OR EMPLO YER

d. ARE YOU A U .S. CITIZEN?

BIRTH

IDENTIFICATION NUMBER

YES

f. OTHER NAMES USED (Maiden name, nicknames, etc.)

MALE

FEMALE

g. RESIDENCE(S) OVER THE LAST FIVE YEARS

10. HAS THE APPLICANT OR ANY PERSON LISTED FOR ITEMS 8 OR 9 EVER BEEN DENIED A PERMIT, LICENSE, OR OTHER AUTHORIZATION

TO ENGAGE IN ANY BUSINESS TO MANUFACTURE, DISTRIBUTE, IMPORT, SELL, OR USE ALCOHOL PRODUCTS (beverage or nonbeverage)

BY ANY GOVERNMENT AGENCY (Federal, State, local, or foreign) OR HAD SUCH PERMIT, LICENSE, OR OTHER AUTHORIZATION REVOKED,

SUSPENDED, OR OTHERWISE TERMINATED?

YES. State details of each event on a separate sheet.

11. HAS THE APPLICANT OR ANY PERSON LISTED FOR ITEMS 8 OR 9 EVER BEEN ARRESTED FOR, CHARGED WITH, OR CONVICTED OF ANY

CRIME UNDER FEDERAL, STATE, OR FOREIGN LAWS other than traffic violations or convictions that are not felonies under Federal or State law.

YES. State details of each event on a separate sheet.

TTB MAY REQUIRE additional information to process this application. If you are applying for a basic permit to operate a distilled spirits plant or

bonded wine premises, you must also file additional forms and information required under the Internal Revenue Code. OPERATION WITHOUT A

PERMIT. Criminal and administrative actions may be taken against persons engaged in a business listed in Item 6 of this form if it is n ot conducted

pursuant to an FAA Act basic permit.

APPLICANT'S AFFIRMATION. Under penalties of perjury, I declare that I have examined this application, including accompanying s tatements, and

to the best of my knowledge and belief, it is true, correct, and complete. The applicant must immediately notify the TTB official with whom this applica-

tion is filed of any change in ownership, management, or control of the applicant (in the case of a corporation, any change in the officers, directors, or

persons holding 10 percent or more of the corporate stock). The business for which this application is made does not violate the law of the State in

which the business will be conducted. In addition, if this application is approved, the applicant will conduct operations within a reasonable period of

time and maintain such operations in conformity with Federal law.

14. DATE

12. APPLICANT'S SIGNATURE (Sole owner, partner, corporate

13. TITLE OF PERSON SIGNING

officer, LLC member or manager, or if designated agent, submit

TTB F 5000.8)

15. E-MAIL (INTERNET) ADDRESS

(optional) :

TTB F 5100.24 (

)

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