Form Rv-F1321301 - Notice Of Wholesaler Change Or Beer Wholesaler Territorial Designation Change Page 2

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7. Description of present assigned territory. (If a county or city is divided by this assignment, define in detail that part of
the county or city so assigned):
8. Description of proposed assigned territory. (If a county or city is divided by this assignment, define in detail that part of the
county or city so assigned):
9. Reason(s) for the proposed wholesaler change or wholesaler territorial designation change:
10.
Signature & title of manufacturer or importer agent
NOTARY PUBLIC
11.
Signature & title of proposed wholesaler
NOTARY PUBLIC
12.
(if waiver of ninety (90) days waiting period is agreeable)
Signature & title of present wholesaler
NOTARY PUBLIC
FOR DEPARTMENT OF REVENUE USE ONLY
Approved:
Effective Date:

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