Form Abl 107c - Abl 107 Checklist (Page 9 of 13) in pdf

Form Abl 107c - Abl 107 Checklist Page 9

STATE OF SOUTH CAROLINA

1350

DEPARTMENT OF REVENUE

ABL-107B

APPLICATION FOR REGISTRATION

(Rev. 10/6/14)

4290

OF PRODUCER/IMPORTER REPRESENTATIVE

Mail to: SC Department of Revenue, ABL Section, Columbia, SC 29214-0907.

File Number:

PLEASE PRINT OR TYPE ALL INFORMATION

Fee: $250 Biennially

(Expires August 31 in even numbered years)

In accordance with Title 61, Chapter 6, Article 7 Code of Laws for SC, 1976, as amended, the undersigned does hereby

make application for registration as the South Carolina representative of the following Registered Producer:

Registered Producer/Importer:

Physical Address:

Mailing Address:

and for that purpose submit the following information:

1. Name of Representative:

2. Business Address:

Street

City

County(required)

State

Zip

3. Is the business within SC Municipal Limits?

Yes

If yes, which city?

4. Are you a resident of South Carolina?

How long?

Must be a resident of South Carolina for 30 days prior to applying.

5. Do you have a direct or indirect interest in a wholesale or retail liquor business in South Carolina?

Yes

6. Telephone number where you can be reached during business hours:

7. I do hereby certify that the SC Department of Revenue shall have the right within statutory limitations to audit and

examine the books and records, papers, and memoranda of the applicant, with respect to the administration and

enforcement of laws administered by the SC Department of Revenue and the South Carolina Law Enforcement Division.

I have read the instructions to this application and to the best of my knowledge, all information provided with this

application is true and accurate.

SWORN to and subscribed before me this

day of

, year of

Applicant Signature

Notary Public for

My Commission Expires:

Notary (L.S.)

Notary (printed name)

42901025

Form Abl 107c - Abl 107 Checklist Page 9

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