North Dakota > Statewide > Office Of State Tax Commissioner > Alcoholic Beverage
Application For Wholesale Beer Or Liquor License 59455 - North Dakota
| Application For Wholesale Beer Or Liquor 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 Wholesale Beer or Liquor License For Year ND License Number (renewals only) FEIN Federal Basic Permit Number City City Contact Person Email State State Zip Code Zip Code New Legal Name DBA (if applicable) Physical Address Mailing Address Telephone Number Renewal Any Information Changed From Previous Application Type of Business: Sole Proprietorship Partnership Corporation Annual Fees: Initial Filers are eligible for prorated fees based on the following table: Wholesale Beer License ($200.00) . . . . . . . . . Wholesale Liquor License ($1,000.00) . . . . . . April - June 30 $150.00 $750.00 July 1 - December 31 $100.00 $500.00 All Applicants: 1. Do you have any financial interest in any retail alcoholic beverage establishment? (If corporation, include all officers, directors and stockholders; if partnership, include all partners.) If yes, list establishments below . . . . . . . . . . . . . . . . . Yes No 2. Does any alcoholic beverage manufacturer or alcoholic beverage retailer have any financial interest in this wholesale business? If yes, list below . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 3. Do you have a warehouse and office in North Dakota (or for beer, in a state which has reciprocity with North Dakota regarding this provision) which contains a complete record of all your North Dakota transactions? If yes, list all locations below, including addresses and managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Street Address, City, State & Zip Code Manager Yes No For Tax Department Use Only American LegalNet, Inc. www.FormsWorkFlow.com Individuals and Partnership: 4. If partnership, list all partners: 5. Are all partners citizens of the United States and residents of North Dakota? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. Have any partners ever been convicted of a felony? If yes, list name and explain below . . . . . . . . . . . . . . . . . . . . . . . Yes Yes No No Corporations: 7. Are you properly registered with the North Dakota Secretary of State? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. Is your manager a resident of the State of North Dakota? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. Has your manager ever been convicted of a felony? If yes, list name and explain below . . . . . . . . . . . . . . . . . . . . . . . Yes Yes Yes No No No 10. Are all officers, directors, and stockholders citizens of the United States? List those persons below . . . . . . . . . . . . . . Yes No 11. Have any officers, directors, or stockholders ever been convicted of a felony? If yes, list name and explain below . . . Yes No 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 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 59455 Rev. 10/10 American LegalNet, Inc. www.FormsWorkFlow.com
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