Department of Revenue
Alcoholic Beverage Licensing
301 Gervais St., PO Box 125
Columbia, SC 29214
(803) 734-0470
Application for Registration of Brands of Alcoholic Liquors
For license year ending August 31, 19______
In accordance with Chapter 7, Title 61, Code of Laws for SC, 1976, as amended, the Registered Producer noted
below does hereby make application to register the following brands of alcoholic liquors for shipment into the
State of South Carolina.
Registered producer address:__________________________________________________________________
___________________________________________________________________________________________
List certificate #_______________________________ or check if application for certificate pending (
).
Contact person:___________________________________ Telephone (
)________________________
INSTRUCTIONS: You must list all brands you intend to ship. If additional space is needed, this form may
be reproduced. YOU MUST SUBMIT THIS FORM IN DUPLICATE.
___________________________________________________________________________________________
Brand Name (list full brand name)
Age
Proof
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FEES: There is no fee for the first five (5) brands registered. The fee for each additional brand over five is
$10.00 per brand. Total fees submitted $______________________
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Department of Revenue Use Only (Do not write in this space)
Brands approved by:__________________________________
Date:________________________________
ABL 107A Rev 9/95