Application For Supplier Representative Permit For Spirituous Liquor (Page 2 of 2) in pdf

Application For Supplier Representative Permit For Spirituous Liquor Page 2

11. Have you ever been convicted of violating any criminal law? ____Yes ____No

If yes, give reason for

conviction: _____________________________________________________________________________

______________________________________________________________________________________

12. Attach a Criminal Record Check or a certified copy of a court record(s) from the last jurisdiction

where you have maintained residence for one year or more. If there is no record, please have the clerk of the

court in the jurisdiction so certify.

13. Application MUST BE NOTARIZED.

By signing this request for a

Distiller Representative's

Permit, you fully understand that, if issued,

this permit can, at the discretion of the Commission, be revoked, suspended or annulled at any

time.

_____________________________________________________________________________________________

Signature

Date

Sworn to and subscribed before me on this the __________day of ________________20________

My commission expires: ____________________________________________________

__________________________________________

Notary

Mail to:

ATTN: Cathy Horne

North Carolina ABC Commission

400 East Tryon Road

Raleigh NC 27610

3/7/2014

Application For Supplier Representative Permit For Spirituous Liquor Page 2