Form Tp-215 - Application For Registration As A Distributor Of Alcoholic Beverages (Page 2 of 2) in pdf

Page 2 of 2 TP-215 (1/15)

Section C – List owners, officers, directors, partners, and other responsible individuals

(Attach additional sheets if necessary; see instructions)

Name

Social security number

Percentage of ownership

(number and street)

Home address

Title

City

State

ZIP code

Duties (a-g)

Telephone number

(see instructions)

(

)

Name

Social security number

Percentage of ownership

(number and street)

Home address

Title

City

State

ZIP code

Duties (a-g)

Telephone number

(see instructions)

(

)

Enter the percentage of voting stock held by all other owners not listed in this section.

(The total percentage of voting stock must equal 100%)

......................................................................................................

During the last five years, has the applicant or any responsible individual listed above either (a) owned or controlled, directly or indirectly, more than

10% of the voting stock (25% or more if four or fewer shareholders own or control the voting stock) of a business other than the one for which you are

applying or (b) been an officer, director, or partner of a business other than the one for which you are applying?

Yes – Complete the following. Attach additional sheets if necessary.

Name of applicant or other responsible individual

Federal EIN

Name of other business

Address (number, street, city, state, ZIP code)

Name of applicant or other responsible individual

Federal EIN

Name of other business

Address (number, street, city, state, ZIP code)

Section D – Checklist

This application will not be approved unless the following information is completed:

Did you mark an X in a box(es) indicating which registration(s) you are applying for as a distributor of alcoholic beverages?

Did you complete section A for the business identification of the applicant?

Did you mark an X in section A indicating your entity type (sole proprietorship, partnership, corporation, etc)?

Have you applied for your New York State Liquor Authority license and New York State Certificate of Authority? Be sure to complete section B.

Did you complete section C for owners, officers, directors, partners, and other responsible individuals?

Did you answer the question in section C and provide the requested information if the applicant or any person included in sections A or C owned

or controlled voting stock of another business during the last five years?

Did you resolve all open tax liabilities for the applicant or owners, officers, directors, partners, and responsible individuals

(see instructions)?

Are you current with all tax returns required to be filed for the applicant or owners, officers, directors, partners, and responsible individuals

(see

instructions)?

Did a person listed in section C, as owner or responsible person, sign the application?

Mail completed application and all required documents to:

NYS TAx DEPARTMENT, TDAB/FACCTS-REgISTRATION AND BOND UNIT, W A HARRIMAN CAMPUS, ALBANY NY 12227-2993

Certification: I certify that, to the best of my knowledge and belief, this application is correct and complete. I understand that a willfully false

representation is a crime under section 1813 of the New York State Tax Law.

Date

Signature

Title

Form Tp-215 - Application For Registration As A Distributor Of Alcoholic Beverages Page 2

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