Form Att-104 - Application For Brand And Label Registration And Designation Of Sales Territory - State Of Georgia Alcohol & Tobacco Division Page 3

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ATT-104 (Rev. 1/13)
STATE OF GEORGIA
ALCOHOL & TOBACCO DIVISION
BRAND/BRAND LABEL(S) REGISTRATION AND DESIGNATION OF SALES TERRITORY
LEGAL NAME
D/B/A
STI NUMBER/LICENSE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
NAME OF DESIGNATED GEORGIA WHOLESALER (IF APPLICABLE)
GEORGIA DISTRIBUTOR LICENSE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
[ ] Malt Beverage
[ ] Wine
[ ] Distilled Spirits
[ ] Wine Special Order Shipping
ASSIGNED TERRITORIES
FULL BRAND / BRAND LABEL NAME
% OF ALCOHOL
(LIST IN ALPHABETICAL ORDER)
LIST IN ALPHABETICAL ORDER
CONTENT BY
*N/A For Wine Special Order Shipping Only
VOLUME
Only List "Entire State" If Distributor Has A Single Location
1.
2.
3.
4.
5.
6.
7.
8.
9.
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15.
16.
17.
18.
19.
20.
BRAND(S) / BRAND LABEL(S) HAVE BEEN PREVIOUSLY SHIPPED TO A WHOLESALE DISTRIBUTOR IN THE STATE OF GEORGIA.
N/A
NO
YES: LIST THE SHIPPER AND WHOLESALE DISTRIBUTOR(S)
1. IF APPLICANT IS NOT THE PRODUCER OF THE BRAND(S), THE REGISTRATION MUST BE ACCOMPANIED BY A CERTIFICATE OF AUTHORITY
FROM THE PRODUCER OF EACH BRAND BEING REGISTERED GIVING THE APPLICANT EXCLUSIVE RIGHTS TO DISTRBUTE THESE BRAND(S).
(EXCLUDES WINE SPECIAL ORDER SHIPPING). THE PRODUCER IS DETERMINED BY NAME INDICATED ON LABEL.
2. A SEPARATE FORM MUST BE COMPLETED FOR EACH GEORGIA DISTRIBUTOR BEING DESIGNATED BY A SUPPLIER WITH A SEPARATE
REGISTRATION FOR EACH WAREHOUSE LOCATION. (EXCLUDES WINE SPECIAL ORDER SHIPPING).
SIGNATURE
TITLE
DATE
SIGNATURE MUST BE MADE BY AN OWNER OR OFFICER OF THE COMPANY REGISTERED WITH THE DEPARTMENT OF REVENUE.
ALL OTHER SIGNATURES REQUIRE A POWER OF ATTORNEY AUTHORIZATION TO BE COMPLETED ON FORM RD-1061.

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