Form Ab-115 - Wisconsin Liquor/wine Permit Application Page 6
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8PERMITTEES STATEMENT OF BRAND
FRANCHISE AND SALES AREA DESIGNATION
Permit Number
Legal Name
Zip Code
Street Address
City
State
PERMITTEES STATEMENT OF BRAND FRANCHISE AND SALES AREA DESIGNATION
No Wisconsin liquor wholesaler may sell any distilled spirits or wine in Wisconsin until a written statement is filed with the department
indicating that (1) the permittee is a distributor of a particular brand of liquor in Wisconsin, and (2) sales of the brand by the permittee and
anyone purchasing from the permittee will be limited to the franchise sales area specified. The permittee shall notify the department of
any change in the area within seven days of the effective date of the change (sec.125.54(5), Wis.Stats.).
Attach a list if more space is needed and check the box indicating that a list is attached.
Manufacturer
Franchise Sales Area
(Name, City, State)
Brand or Brand Name
(Counties or portion of counties)
SIGNATURE
(All applicants must sign)
I declare under penalties of the law that I have examined this information and, to the best of my knowledge, it is true, correct, and complete.
Signature (do not print or type)
Title
Date
Signature (do not print or type)
Title
Date
If applicant is a corporation, the president and the secretary must sign. If applicant is a partnership, two partners must sign. If applicant is a limited liability
company, two members must sign unless the limited liability company only has one member.
AB-115
Wisconsin Department of Revenue
-6-
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