Form At-107a - Schedule For Successor Of Agent

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CHANGE OF AGENT FEE $10.00
SCHEDULE FOR
SUCCESSOR OF AGENT
If there is a change in agent, each club, corporation, or limited liability company who holds a retail permit to sell fermented malt bever-
ages and/or intoxicating liquor must appoint a successor agent pursuant to sec. 125.04(6), Wis. Stats. The following questons must
be answered by the Agent. The appointment must be signed by the President and Secretary or members of limited liability company.
The apppointment must be approved by the proper local official.
Wisconsin
20
(Municipality)
(Date)
1. Name of agent
2. Are you of legal drinking age?
Yes
No
Yes
3. Have you been a resident of Wisconsin for at least 90 continuous days prior to the date of appointment as agent?
No
No
4. Have you ever been convicted of a federal law violation?
State law violation?
Yes
Yes
No
Local ordinance violation?
Yes
No
Explain
5. Previous occupation
UNDER PENALTY OF LAW, I declare that all of the above information is true and correct to the best of my knowledge and belief.
(Signature of Agent)
(Address)
SUCCESSOR AGENT
The undersigned appoints
as agent
in accordance with sec. 125.04(6), Wis. Stats.
Name of Permittee
20
Date
By
(Signature of President/Member)
(Signature of Secretary/Member)
I hereby accept appointment as agent for
and assume
full responsibility or the conduct of the business relative to fermented malt beverages and intoxicating liquors.
Date
20
(Signature of Agent)
THE AGENT APPOINTED ABOVE MUST BE APPROVED AS FOLLOWS:
(a) In towns, by the Town Chairman
(b) In villages, by the President of the Village
(c) In cities, by the Chief of Police
The appointment above is herewith approved.
Wis.,
20
(Municipality)
(Date)
(Signature of Official)
(Title)
AT-107a (R. 9-08)
Wisconsin Department of Revenue

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