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STATE OF MAINE BUREAU OF ALCOHOLIC BEVERAGES AND LOTTERY OPERATIONS DIVISION OF LIQUOR LICENSING & ENFORCEMENT 8 STATE HOUSE STATION , AUGUSTA, ME 04333 - 0 008 Phone: (207) 287 - 4482 or (207) 287 - 4492 REPORT OF TABLE WINE SHIPMENTS 15.5% Alcohol or Less By Holders of a Wine Certificate of Approval Issued by the Division Authorizing the Sale of Table Wine to Wholesaler Licensees within the State Report for the Month of 20 This record shall be filed with the liquor licensing & Enfor cement Division, Augusta, Maine on or before the 15 th day of each calendar month. Name: Address: Permit or License # *** EMAIL*** Name of Wholesaler Maine Purchase Order Number Invoice Number Invoice Date Total Gallonage Per Invoice ***Please Include All listed Invoice(s) with this report. *** Total Gallons Shipped: Dated at This day of ,20 State of By: By: If a corporation, report must be signed by duly authorized officer. (Printed Name) Table Wine Shipments F orm Rev. 11 - 2018 Replaced 9 - 2016 American LegalNet, Inc. www.FormsWorkFlow.com