Form B-C-785 - Registration Form Wine Shipper Permittee printable pdf download

Form B-C-785 - Registration Form Wine Shipper Permittee

B-C-785

Registration Form

Web

Wine Shipper Permittee

3-07

North Carolina Department of Revenue

Federal Employer ID Number:

Wine Shipper Permit Number:

Type of Form

Initial Registration

Change in Registration Information

(Check One)

Legal Name:

Trade Name (DBA Name):

Street Address:

Street

City

State

Zip Code

County

Mailing Address: Street or P.O. Box

City

State

Zip Code

County

Name of Contact Person:

Telephone:

Fax:

Mailing Address: Street or P.O. Box

City

State

Zip Code

County

Each winery that has been issued a wine shipper permit by the North Carolina Alcoholic Beverage Control

Commission is required to register with the Department of Revenue pursuant to G.S. 18B-1001.1. Please

complete this registration form in detail. The wine shipper permittee must notify this office of any changes

in the registration information provided on this form as such changes occur.

North Carolina Department of Revenue, Alcoholic Beverage and Amusement Tax Unit,

Post Office Box 25000, Raleigh, North Carolina 27640-0110

Form B-C-785 - Registration Form Wine Shipper Permittee