Form Ber 115 - Application For Beer Certificate Of Registration For Manufacturers/importers
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2TENNESSEE DEPARTMENT OF REVENUE
500 DEADERICK STREET
ANDREW JACKSON STATE OFFICE BUILDING
NASHVILLE, TN 37242
BER
APPLICATION FOR BEER CERTIFICATE OF REGISTRATION
115
FOR MANUFACTURERS/IMPORTERS
BUSINESS NAME AND EXACT LOCATION
BUSINESS MAILING ADDRESS
Owner Name __________________________________
Trade Name ______________________________
Address 1 ____________________________________
Address 1 ________________________________
Address 2 ____________________________________
Address 2 ________________________________
City, State, Zip _________________________________
City, State, Zip ____________________________
Business Phone _______________________________
Is business located inside city limits? Yes ( ) No ( )
If "yes", specify city _________________________
Please complete this application and return it to this office with the appropriate remittance as shown on the bottom of this
notice. All questions must be answered completely for your application to be processed.
Any person failing to apply for a certificate of registration upon entering business or failing to obtain a renewal certificate by
January 20th of each year will be penalized $5.00 for each month or part of a month the application is late. Penalty will not
exceed the cost of the certificate.
For additional information regarding this application you may call Taxpayer Services between 8:00 a.m. and 4:30 p.m. (CT),
Monday through Friday, holidays excepted. Please see the back of this notice for our local offices and phone numbers.
Type of Ownership: ( ) Proprietorship ( ) Partnership ( ) Corporation
SSN
FEIN
IDENTIFY OWNERS, OFFICERS, OR PARTNERS (if more space is required attach additional sheets).
(1) Name ___________________________________
(2) Name ________________________________
Address _________________________________
Address ______________________________
City, State, Zip Code _______________________
City, State, Zip Code ____________________
________________________________________
_____________________________________
Phone No. _______________________________
Phone No. ____________________________
1. Manufacturer/Importer ($40.00) _________________
FOR OFFICE
2. Penalty (see above) __________________________
USE ONLY
3. Total amount of payment $ _____________________
MAKE CHECK PAYABLE TO:
TENNESSEE DEPARTMENTOF REVENUE
Under penalties of perjury, I declare that the statements in this application are true and correct to the best of my knowledge
and belief. This application applies only to the specified business and location listed hereon.
Authorized Signature & Title
Date
RV-R0007301 (Rev. 4-03)
INTERNET (Rev. 4-03)
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