Form Ab-115 - Wisconsin Liquor/wine Permit Application Page 4
ADVERTISEMENT
1
2
3
4
5
6
7
8VERIFICATION
(Complete only ONE of the following three sections.)
INDIVIDUAL
I declare under the penalties of law that I am the applicant named and that the answers to the questions in this
application and the attached Auxiliary Questionnaire are true, correct, and complete and that application has not been
made for more than one other Wisconsin wholesaler, manufacturer, rectifier, winery, or wholesale alcohol permit.
Printed Name
Title
Phone Number
Signature
Date
INDIVIDUAL
SIGN HERE
PARTNERSHIP
and
declare under the penalties of law that we are members of a partnership consisting of themselves and
doing business under the legal name of
and that we have read the foregoing application and attached Auxiliary Question-
naires and know that each of the answers is true, correct, and complete and that application has not been made for more
than one other Wisconsin wholesaler, manufacturer, rectifier, winery, or wholesale alcohol permit.
Printed Name
Title
Phone Number
Signature
Date
PARTNER
SIGN HERE
Title
Printed Name
Phone Number
Date
Signature
PARTNER
SIGN HERE
CORPORATION/LIMITED LIABILITY COMPANY
and
declare under the penalties of law that we are Officers/Members respectively of
, a corporation/limited liability company registered
(date)
and existing under the laws of Wisconsin, with its principal place of business at
and are authorized to make this application on behalf of said corporation/limited liability company and know that each of the
answers in the foregoing application and attached Auxiliary Questionnaire is true, correct and complete, and that application
has not been made for more than one other Wisconsin wholesaler, manufacturer, rectifier, winery, or wholesale alcohol permit.
Title
Printed Name
Phone Number
Date
Signature
PRESIDENT
SIGN HERE
Printed Name
Title
Phone Number
Signature
Date
SECRETARY
SIGN HERE
AB-115
Wisconsin Department of Revenue
-4-
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial