Form Att-104 - Brand And Label Registration And Designation Of Sales Territory

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ATT-104
STATE OF GEORGIA
ALCOHOL & TOBACCO DIVISION
BRAND AND LABEL REGISTRATION AND DESIGNATION
OF SALES TERRITORY
(This form must be completed on each Georgia Distributor being designated, i.e. each house must have a separate sheet )
CITY
NAME OF DESIGNATED GEORGIA WHOLESALER
[ ] MALT BEVERAGE
[ ] WINE
[ ] DISTILLED SPIRITS
COMPLETE THE FOLLOWING IN FULL
FULL BRAND NAME
% OF ALCOHOL
ASSIGNED TERRITORIES
LABEL NUMBER
CONTENT BY
(List in Alphabetical Order)
(List Counties in Alphabetical Order)
(OFFICE USE ONLY)
VOLUME
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
NOTE:
IF APPLICANT IS NOT THE PRODUCER OF THE BRAND(S), THE APPLICATION MUST BE ACCOMPANIED BY A LETTER OF
AUTHORITY FROM THE PRODUCER OF EACH BRAND BEING REGISTERED GIVING THE APPLICANT EXCLUSIVE RIGHTS TO
DISTRIBUTE THOSE BRAND(S).
NAME OF LICENSED SHIPPER
STATE TAXPAYER I.D. # / GA LICENSE #
SIGNATURE / TITLE
DATE

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