Form Dr 8440 - Sole Source Of Supply/brand Registration Form

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DR 8440 (12/00)
COLORADO DEPARTMENT OF REVENUE
LIQUOR ENFORCEMENT DIVISION
1375 SHERMAN ST
COLORADO LICENSED
DENVER CO 80261
(303) 205-2300
IMPORTERS/MANUFACTURERS
Sole Source of Supply/Brand Registration Form
For Sole Source Applications:
See instructions on back page
For New Product Registrations:
See instructions on back page
DO NOT WRITE IN THIS SPACE
Colorado License Number
ALL IMPORTERS AND MANUFACTURERS FILL OUT THIS SECTION
Applicant Name
Federal Basic Permit Number
Trade Name
Telephone Number
Mailing Address (Street Number, City, State, ZIP)
Colorado Wholesaler(s) Product(s) will be shipped to
SOLE SOURCE APPLICATIONS
Name of Primary Source
Telephone Number
Federal Permit Number
Address of Primary Source (Street Number, Box Number, Rte., City, State, ZIP)
NEW PRODUCT REGISTRATION
Product Name
1.
4.
5.
2.
3.
6.
Sole Source Registration
2240-100 (999)
$100 x _____________________
Total Fee: _________________________
Product Registration
2290-100 (999)
$5.00 x _____________________
Total Fee: _________________________
DR 8440 (12/00)
COLORADO LICENSED
IMPORTERS/MANUFACTURERS
Sole Source of Supply/Brand Registration Form
Name of Importer
Colorado License Number
Period
Sole Source Registration ............................
2240-100 (999)
$100 x _________
Product Registration ....................................
2290-100 (999)
$5.00 x _________
TOTAL
▲

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