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Schedule A Agents Solicitors Out-Of-State Brewer Out-Of-State Microbrewer And Beer Importer License - Kentucky
| Schedule A Agents Solicitors Out-Of-State Brewer Out-Of-State Microbrewer And Beer Importer License Form. This is a Kentucky form and can be used in Licensing Alcohol Beverage Control Statewide . |
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Page 1- Schedule-A 03/01/2011 Site I.D. # Schedule "A" Agent's, Solicitor's, Out-Of-State Brewer, Out-Of-State Microbrewer, and Beer Importer License Leave Blank For ABC Use Only License # Malt Beverage Administrator's Approval Distilled Spirits Administrator's Approval $ Validating Number Date Date (A) Applicant's name(s) or company to be licensed DBA (Name of Business) Address of premises to be licensed City Mailing address if different from above City Telephone List the type(s) of licenses(s) you are applying for Enter amount of fee enclosed $ Enter the date you want this license to become effective County Fax State 9 digit zip code Other Phone County State 9 digit zip code - (B) 1. Does anyone named in this application have an interest in any kind of alcoholic beverage business (es) or the premises (s) of any alcoholic beverage business (es) other than that for which you are herein applying? If yes, describe the interest(s). a. Has the applicant or any person named in this application been convicted of any felony in the past five (5) years? b. Has the applicant or any person named in this application been convicted of a misdemeanor directly or indirectly related to alcohol or a controlled substance in the past two (2) years? If yes, to either question you must attach a statement giving a full explanation, including dates of conviction(s). Has a license been suspended, revoked or denied for the premises or any person named herein? If yes, attach a statement giving a full explanation, including dates of suspension, revocation, or denial. YES NO 2. YES YES NO NO 3. YES NO (C) 4. Are you applying for an Agent's or Solicitor's Liquor & Wine License under KRS 243.340 or a Non-Resident Agent's or Solicitor's Liquor and Wine License under 804 KAR 4:020? If yes, please complete the following. If no, skip to question #5. a. Give the following information for the past two years: Name of Employer Date of Employment: Present Employer Kentucky State ABC License Number b. c. Do you plan to work for a retail licensee while holding this solicitor's license? Do you have any relatives holding a retail License? If yes, describe the interest(s). d. Give the following information: Your Social Security # Are you a Kentucky Resident? Are you a USA Citizen? e. YES YES NO NO ,a principal officer of does hereby offer employment as a solicitor or sales Date American LegalNet, Inc. www.FormsWorkFlow.com Address From To Address YES YES NO NO Your home address , and your Date of Birth If yes, give date you established residency. Your employer must sign the following: I, Company, holder of Kentucky State ABC License Number representative to the above applicant. Employer's Signature Page2- Schedule-A 03/01/2011 Schedule "A" Page (2) Site I.D. # (D) 5. Are you applying for an Out-of-State Brewer License, (importing 25,000 or more barrels (775,000) of malt beverages annually?)) or a Limited Out-of-State Brewer or Microbrewery License, (importing 25,000 barrels or less (775,000 gallons of malt beverages annually?)) Under 804 KAR 4:350. If your answer is No, skip to section F. a. Pursuant to KRS 243.180 and KRS 244.560, are you a licensed If yes, give the state where you are licensed b. Are you a licensed importer of a non-US brand of malt beverages? If yes, list the state where you are licensed c. d. e. f. g. h. List the brand(s) of malt beverages to be imported into Kentucky. Will the above-mentioned brand(s) be distributed from your warehouse? What is the address of your warehouse? Have you attached an actual label of your beer(s) that has been approved by the Federal Department of Treasury (TTB) Alcohol, Tobacco Tax and Trade Bureau, and a copy of their (COLA) Certificate of Label Approval for such label(s)? Have you attached a copy of your territorial agreement filed with the Kentucky Office of Alcoholic Beverage Control, which has been signed and dated? (ABC Form 714) Are you an importer of a foreign beer? If yes, have you attached authorization from the foreign brewery authorizing you to name a Kentucky Distributor to distribute the beer in a designated territory? (E) Complete the following for the business proprietor, partner(s) and all persons interested in the business to be licensed. List all owners, officers, directors, partners, managing members, members, and shareholders (unless publicly held). Show 100% of the ownership. If additional space is needed, please make an attachment. ALL PHONE NUMBERS H= HOME W= WORK F= FAX O= OTHER H W F O H W F O YES NO Date % State YES NO Date State % SOCIAL SECURITY NUMBER LIST DATE & STATE % OF WHERE YOU RESIDED IN OWNERSHIP PAST 5 YRS YES NO and your license number beer wholesaler, or a beer distributor? YES NO and your license number YES NO YES NO YES YES YES NO NO NO NAME AND ADDRESS TITLE USA CITIZEN DATE OF BIRTH (F) AFFIDAVIT OF PERSON APPLYING FOR THE KENTUCKY ABC LICENSE (S) do hereby swear or affirm that all statements contained in I, (print your name here) this application and all its attachments are true and correct to the best of my knowledge, information and belief. I further agree that I shall not engage in any activity involving alcoholic beverages at the premises described herein until I have been issued the appropriate license(s) by the Department of Alcoholic Beverage Control. Once the license(s) is issued, I hereby swear or affirm that I shall abide by all state and local statutes, regulations, and ordinances relating to the manufacture, sale, use, and trafficking in alcoholic beverages. I also swear or affirm that no persons listed in Section D-7 of this application are in default of a repayment obligation, such as a student loan repayment, under any financial program administered by a Kentucky Higher Education Assistance Authority (KHEAA). KRS 164.772. Signature of Applicant Sworn or affirmed before me on this Notary Public day of Title ,year of Date . My commission expires ,State of County of (Canadian applicants are exempt from this notary requirement) American LegalNet, Inc. www.FormsWorkFlow.com Page 3- Schedule-A 03/01/2011 Schedule "A" TYPES OF LICENSES & FEES Check the box(s) for the type(s) of license(s) you are applying for. To determine the ABC State License(s) fee, find the license type(s) in the left column, and then move right across the table to the fee boxes. Figure from the month your license will be issued. Licenses that are issued 6 months or more pay a full year fee and Licenses that are issued 6 months or less pay a ha
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