Sd Eform 0869 - State Of South Dakota Alcoholic Beverage Brand - Label Registration Application

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SD EForm - 0869
V4
Complete and use the button at the end to print for mailing.
HELP
State of South Dakota Alcoholic Beverage Brand - Label Registration
Application
Revised
11/14
South Dakota Department of Revenue
Special Tax Division
445 E. Capitol Ave | Pierre, SD 57501-3100
Applicant Name:
Mailing Address:
Phone:
Basic Federal Permit No.:
Fax:
E-mail Address:
Application is hereby made for the registration of the Alcoholic Beverage Brand-Labels herein listed which will be offered for sale
or held with intent to sell within the State of South Dakota in accordance with Chapter 39-13 and Section 10-1-14(2), South Dakota
Codified Laws for the calendar year:
.
CLASS NUMBER
BRAND
PRODUCT LABEL
%
FEE
0.00
Additional sheets may be attached if required
Total Fee: $
I, the undersigned, an official of and for the above applicant, do hereby certify that the above products and labels conform to
Laws and Regulations of the State of South Dakota applicable to Alcoholic Beverages and have been registered with and
approved by the Alcohol and Tobacco Tax and Trade Bureau under the Federal Alcohol Administration Act.
Date
Signed
Title
For Department Use
Application Rec’d:
License No:
Total Registration Fee Rec’d:
Additional Fee Due:
Label Registrations Approved:
Denied:
Date:
Exceptions:
Signed:
Special Tax Division, Department of Revenue
SEE INSTRUCTIONS ON REVERSE SIDE
SD REV 11/14
PRINT FOR MAILING
CLEAR FORM

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