Direct Shippers Renewal Application Form Page 2
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4Direct Shippers-RENEWAL
dir-ship-renapp.rev-1/17/13
Please complete all of the fields provided in the form. If the Trade Name has changed since the
last renewal filing you must also include a filing receipt or a certificate of assumed name with the
renewal application. Other changes noted on the renewal application do not constitute proper
notification to the Authority, nor does the approval of the renewal application constitute approval
of any changes listed in the renewal, other than the Trade Name change.
1. Licensed Premises Information
Is your licensed premises closed?
YES
NO
If yes, is your NYS Direct Shippers license in safekeeping with the New York State Liquor Authority?
YES
NO
License Serial #:
Licensed Premises Name:
Effective Date:
Trade Name (if applicable):
Expiration Date:
Federal Employer Identification Number :
A. Does the licensee have a current home state wine manufacturers license? (submit a copy)
YES
NO
B. Does the licensee have a current Federal Basic Permit designating them as a wine producer/blender?
YES
NO
C. Has there been any change in the status or the license/serial numbers of the applicants home state wine manufacturing license
and/or Federal Basic Permit?
YES
NO
If yes, list changes:
PLEASE NOTE:
If the licensees physical manufacturing/production location has been changed, you must
re-apply for a new license under the new address. DO NOT RENEW THE CURRENT LICENSE
Address of the Licensed Premises
ALL SECTIONS MUST BE COMPLETED IN ORDER TO APPROVE YOUR RENEWAL
If your address has been changed as a result of a 911 change, please provide proof of the change such as notification
of the 911 address change from the local Municipality/Community Board or notification from the Post Office.
Licensed Premises Address:
City:
State:
Zip Code:
County:
Email Address:
Premises Telephone # (include area code):
Contact Phone # (include area code):
Mailing Address (if different than premises address)
Mailing Address:
City:
State:
Zip Code:
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