Form Ab-115 - Wisconsin Liquor/wine Permit Application Page 3
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820. (Wholesaler applicants only). List the names, addresses, and license/permit numbers of at least 10 retailers/permittees that you intend to
sell intoxicating liquor to:
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If a corporation or LLC, list name and address of each stockholder or member and indicate the percent of stock or interest held.
Percent of Stock
Address
Name
or Interest Held
(If additional space is required, attach a supplemental schedule)
I
declare under the penalties of law that I have examined this information and, to the best of my knowledge and belief, it is true, correct,
and complete.
Printed Name
Title/Member
Signature
Phone Number
Date
AB-115
Wisconsin Department of Revenue
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