Form At-212 - Application For Vessel Permit - Wisconsin Department Of Revenue Page 4
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4SCHEDULE FOR APPOINTMENT OF AGENT
Each corporation applying for a Class “B” fermented malt beverage and/or “Class B” intoxicating liquor permit under Sections 125.27(2)
and 125.51(5)(c) must appoint an agent pursuant to Section 125.04(6), Wisconsin Statutes. The following questions must be answered
by the agent, the appointment must be signed by the president and secretary of the corporation and the recommendation must be
made by the proper local official.
NAME
ADDRESS
DATE OF BIRTH
NAME OF CORPORATION
OFFICIAL CAPACITY
OCCUPATION
HAVE YOU BEEN A CONTINUOUS RESIDENT OF WISCONSIN FOR AT LEAST 90 DAYS PRIOR TO THE DATE OF APPOINTMENT AS AGENT?
YES
NO
HAVE YOU EVER BEEN CONVICTED OF A VIOLATION OF FEDERAL LAW?
YES
NO
STATE LAW?
YES
NO
LOCAL ORDINANCE?
YES
NO
EXPLAIN FULLY ANY QUESTION ANSWERED YES.
I DECLARE UNDER THE PENALTIES OF LAW THAT THE ABOVE INFORMATION IS TRUE, CORRECT AND COMPLETE.
SIGNATURE
DATE
AGENT SIGN
HERE
APPOINTMENT OF AGENT
APPOINTS
AS AGENT IN ACCORDANCE WITH SECTION 125.04(6), WISCONSIN STATUTES, SUBJECT TO THE APPROVAL OF THE DEPARTMENT OF REVENUE.
SIGNATURE
DATE
PRESIDENT SIGN
HERE
SIGNATURE
DATE
SECRETARY
SIGN HERE
ACCEPTANCE BY AGENT
I HEREBY ACCEPT APPOINTMENT AS AGENT FOR
AND ASSUME FULL
RESPONSIBILITY FOR THE CONDUCT OF THE BUSINESS RELATIVE TO FERMENTED MALT BEVERAGES AND INTOXICATING LIQUOR.
SIGNATURE
DATE
AGENT SIGN
HERE
APPROVAL OF AGENT
THE AGENT APPOINTED ABOVE MUST BE APPROVED AS FOLLOWS:
THE APPOINTMENT ABOVE IS HEREWITH APPROVED.
(A)
IN TOWNS BY THE TOWN CHAIRMAN
(B)
IN VILLAGES BY THE PRESIDENT OF THE VILLAGE
(C)
IN CITIES BY THE CHIEF OF POLICE
WI,
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(SIGNATURE OF OFFICIAL)
TITLE
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