Application For Alcoholic Beverage Control Manufacturer License(S) - Nys Liquor Authority Page 3
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18manu-rev120817
OFFICE USE ONLY
Original
Date ________________
Amended
LICENSE
102
APPLICATION FOR ALCOHOLIC BEVERAGE CONTROL MANUFACTURER LICENSE(S)
It is not necessary to employ any person, agency or organization to assist you in filing this application. Beware of persons claiming to be able to
assist you in securing action on your application. The payment of money or other thing of value for the use of influence, or promise of influence
in obtaining a license is a violation of law and offenders will be prosecuted.
1. APPLICANT
Name of Applicant :
(Sole Proprietor, Partnership, Corporation, LLC, LLP,
LP, etc.)
Trade Name(DBA): (
see instructions) ** must be provided if premises will be
called by any name other than as listed in the "Name of Applicant"
Premises Street Address:
, NY
City:
Zip Code:
County:
Telephone Number of Premises (include area code):
Mailing Address (if different than above):
City:
State:
Zip Code:
E-mail address (required):
Business Website:
2. CONTACT (if different than applicant)
Attorney
Representative
Contact Person
Name of Contact:
Office Address:
City:
State:
Zip Code:
Telephone Number of Office (include area code):
E-mail address (required):
3a. Combined craft manufacturer only :
3. LICENSE TYPE:
CODE:
(see schedule of fees)
LICENSE TYPE:
CODE:
4. TOTAL PAYMENT DUE:
LICENSE TYPE:
CODE:
5.
Federal Tax ID #:
6.
:
Certificate of Authority to Collect NYS Sales Tax
(required if license allows for retail privileges)
[OFFICE USE ONLY]
Combined Craft
____________
______________
SERIAL #:
DATE FILED:
Approved
Disapproved
_________________________
continued on next page
License Board Member
Date
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