STATE OF SOUTH CAROLINA
ABL-107
DEPARTMENT OF REVENUE
APPLICATION FOR CERTIFICATE OF
(Rev. 3/20/00)
4264
PRODUCER OF ALCOHOLIC LIQUORS
For Office Use Only
Mail to: SC Department of Revenue, ABL Section, Columbia, SC 29214-0904.
DLN
File Number
Fees: $200 Biennially - $150 1st fee after March 1
License Period Ending
Amount Paid
14 3951 0006
In accordance with Chapter 7, Title 61, Code of Laws of South Carolina, 1976, as amended the undersigned producer
of alcoholic liquors does hereby make application for Certificate of Registration to ship alcoholic liquors to a point
within the geographic limits of South Carolina, in care of his Producer Representative.
1. Producer's Name
FEI#
Individual, Corporate Charter Name , or Partnership Name
SS#
2. Trade Name (doing Business as)
3. Type of Ownership:
( ) Sole Proprietor
( ) Partnership
( ) LLC/LLP
( ) Unincorporated Association: enter legal name
( ) Corporation: If SC Corporation enter date incorporated
4. If a Corporation, are you a Publicly Traded Corporation?
( ) Yes
( ) No
IE. Listed on a Stock Exchange.
5. Name(s) of business owner, general partners, principals or officers:
SS#
Name/Title/General Partners
Home Address
Date of Birth
6. Business Address:
Street
City
State
Zip Code
7. Mailing Address:
Street
City
State
Zip Code
8. Telephone #: Bus.(
)
Home(
)
The undersigned producer does 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.
I
Full Name
Title
for the firm of
(Producer)
Swear (or affirm) that the information given above is true and correct to the best of my knowledge and belief.
Producer Signature
Approved by
Date
Certificate Issued
Date