North Dakota > Statewide > Office Of State Tax Commissioner > Alcoholic Beverage
Application For Alcoholic Beverage Direct Shipping License 59458 - North Dakota
| Application For Alcoholic Beverage Direct Shipping License Form. This is a North Dakota form and can be used in Alcoholic Beverage Office Of State Tax Commissioner Statewide . |
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North Dakota Office of State Tax Commissioner Application For Alcoholic Beverage Direct Shipping License New Legal Name DBA (if applicable) Physical Address Mailing Address Telephone Number City City Contact Person Email Address Any Information Changed From Previous Application For Year ND License Number FEIN Federal Basic Permit Number State State Zip Code Zip Code Renewal License Fee: $50.00 Type of Business: Sole Proprietorship 1. The state of domicile for this business is 2. Is the business currently a licensed alcoholic beverage manufacturer? License No. , and Expiration Date Yes No Yes No If Yes, enter State of the license. If Yes, enter State of the license. , , Partnership LLP Corporation LLC 3. Is the business currently a licensed alcoholic beverage retailer? License No. , and Expiration Date Agreement to Electronically File The Tax Commissioner agrees to authorize the above named company to electronically file the tax reports and schedules as required under North Dakota Century Code chs. 5-01 and 5-03. The signature of the company affixed to this application shall be deemed to appear on such electronically filed reports and schedules, as if actually so appearing. All reports and schedules filed electronically pursuant to this agreement are deemed by the company to be truthful, accurate and complete statements made under penalty of perjury, and shall be in form compatible with the Tax Commissioner's equipment, software, and facilities. Any electronic filing not in conformity with the requirements specified herein shall be deemed a failure to file such reports and schedules and company shall be subject to all applicable penalties prescribed by law. I declare under the penalties of North Dakota Century Code ยง 12.1-11-02, which provides for a Class A misdemeanor for making a false statement in a governmental matter, that this application has been examined by me and to the best of my knowledge and belief is complete, correct, and true. Name of Owner or Authorized Officer (print or type) Signature of Owner or Authorized Officer Title For Tax Department Use Only Date Please send application and license fee to: Office of State Tax Commissioner Alcohol Tax Section 600 E. Boulevard Ave. Dept. 127 Bismarck, ND 58505-0599 Phone: (701) 328-2702 59458 Rev. 10/10 American LegalNet, Inc. www.FormsWorkFlow.com
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