Application For Supplier Permit For Spirituous Liquor printable pdf download

Application For Supplier Permit For Spirituous Liquor

STATE OF NORTH CAROLINA

ALCOHOLIC BEVERAGE CONTROL COMMISSION

Mailing Address: 4307 Mail Service Center

Raleigh, North Carolina 27699-4307

Phone: 919-779-0700 FAX: 919-661-5927

APPLICATION FOR SUPPLIER PERMIT FOR SPIRITUOUS LIQUOR

Please Provide the Following Information:

Firm Name

Address:

(Street Address, City

, State , Zip Code)

(Name)

(Phone Number)

Nature of Business

(Distiller, Importer)

Location of Plant(s)

Where will shipments originate?

Federal Basic Permit Numbers and Types (This is required.)

Federal Basic Permit Numbers and Types This is required.

(

)

North Carolina Supplier Broker Representative

(Name)

(Street Address, City

, State , Zip Code)

(Phone Number)

Do you have a Certificate of Authority from the N.C. Secretary of States Office?

In Progress ___________

Are any of your employees related in any way to any Commission/ABC Board Member or Employee?

Firm Name

(To be signed by an E

xecutive Officer)

Date

Print Name:

G.S.

18B-1105(

a)(2)

Title:

(Revised 7/28/2010)

______________________________________________________________

Application For Supplier Permit For Spirituous Liquor