Georgia > Statewide > Department Of Revenue > Alcohol And Tobacco Division
Application For Alcohol Permit ATT-15 - Georgia
| Application For Alcohol Permit Form. This is a Georgia form and can be used in Alcohol And Tobacco Division Department Of Revenue Statewide . |
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ATT-15 (Rev. 5/11) APPLICATION FOR ALCOHOL PERMIT INSTRUCTIONS FOR COMPLETION OF THE APPLICATION FOR ALCOHOL PERMIT (ATT-15) Use this form to obtain a permit for any salesmen or representative. Provide a separate application for each applicant. TYPE OR PRINT IN BLUE INK - DO NOT USE PENCIL INSTRUCTIONS FOR COMPLETING: Line 1 Line 2 Enter your Georgia State Taxpayer Identifier. (If you do not have one, leave blank). Enter the name and address under which your business is registered with the Secretary of State. If your business is not registered, then enter the name under which your business owns property or acquires debt. If the business is a partnership, the legal name is the partnership name. In the case of a sole proprietorship, the legal name is the name of the individual owner of the business. Check the type of permit for which you are applying. Provide the following information about the applicant: * Social Security Number * Name of applicant * Date of birth * Home address * Email * Fax number * Home telephone number * Number of years of residency at above address * Previous home address Enter previous home address. Enter the number of years applicant has been employed by company identified in Lines 1 and/or 2. Check "Yes" or "No" in the spaces provided. If Line 14 is yes, provide the following information for each alcoholic beverage business in which the applicant has an interest (if more than one business, attach additional sheets with the information requested below): * State Taxpayer Identifier or business interest * Name of business interest * Alcohol License Number * Business location address * Business telephone number Provide information regarding any previous involvement with government authorities. Provide the following employment history information: * Month and year employed from * Name of previous employer * Address of previous employer * Position applicant held Line 3 Line 4-11 Line 12 Line 13 Line 14 Line 15-19 Line 20 Line 21 American LegalNet, Inc. www.FormsWorkFlow.com ATT-15 (Rev. 5/11) INSTRUCTIONS FOR SIGNING: This application must be signed by the applicant and duly notarized. INSTRUCTIONS FOR PAYMENT: There is no registration fee for a salesman or representative of a licensed wholesaler, importer, or broker of wine or malt beverages or of a licensed winery or brewery. The fee for a salesman or representative of a licensed wholesaler or producer distilled spirits $10.00 per person. A check or money order for the appropriate fee must be made payable to the GEORGIA DEPARTMENT OF REVENUE. Georgia law stipulates that taxes and fees shall be paid in lawful money of the U.S. and be free of any expense to Georgia. Each Salesman or Representative applicant of a licensed liquor wholesaler must complete and attach a Personal Statement (ATT-17) and complete the Georgia Automated Fingerprint Procedure (GAPS). Examiners conducting the investigations for permits will provide an instructional package on how to successfully complete the GAPS registration process. A fee of $52.90 is charged by Cogent Systems to each applicant being fingerprinted. Payment must be at time of registration. Credit card, money order or cashiers check payable to "Cogent Systems-GAPS". INSTRUCTIONS FOR MAILING AND REQUESTING INFORMATION: Confirming company and applicant should retain a copy of this application for his file and for inspection by the Revenue Commissioner or designated Agents. Mail the original to the address shown below. If you have any questions or need assistance in completing the application, call (404) 417-4870. GEORGIA DEPT OF REVENUE ALCOHOL & TOBACCO DIVISION P.O. BOX 49728 ATLANTA, GEORGIA 30359 THE PROCESSING OF THIS APPLICATION WILL BE DELAYED UNLESS IT IS PROPERLY SIGNED, COMPLETE INFORMATION FURNISHED, AND APPLICABLE QUESTIONS ANSWERED. American LegalNet, Inc. www.FormsWorkFlow.com ATT-15 (Rev. 5/11) GEORGIA DEPT OF REVENUE ALCOHOL & TOBACCO DIVISION P.O. BOX 49728 ATLANTA, GEORGIA 30359 OFFICE USE Promotional APPLICATION FOR ALCOHOL PERMIT OFFICE USE ONLY 1. 2. STATE TAXPAYER IDENTIFIER LEGAL BUSINESS NAME LEGAL BUSINESS ADDRESS (City, State, and Zip Code): D/B/A STATE LICENSE NUMBER 3. FOR WHICH TYPE OF PERMIT ARE YOU APPLYING? [ [ [ [ [ 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. [ ] BUSINESSMAN OR REPRESENTATIVE OF A REGISTERED PRODUCER OF DISTILLED SPIRITS - FEE $10.00 ] SALESMAN OR REPRESENTATIVE OF A LICENSED WHOLESALER OF DISTILLED SPIRITS - FEE $10.00 ] SALESMAN OR REPRESENTATIVE OF A LICENSED WHOLESALER OF WINE - NO FEE ] SALESMAN OR REPRESENTATIVE OF A LICENSED WINERY, IMPORTER, OR BROKER OF WINE - NO FEE ] SALESMAN OR REPRESENTATIVE OF A LICENSED BREWERY, IMPORTER, OR BROKER OF MALT BEVERAGES - NO FEE ] SALESMAN OR REPRESENTATIVE OF A LICENSED WHOLESALER OF MALT BEVERAGES - NO FEE LAST, FIRST, MIDDLE INITIAL DATE OF BIRTH SOCIAL SECURITY NUMBER NUMBER AND STREET ADDRESS (Residence) NUMBER AND STREET ADDRESS (Additional Space) CITY AREA CODE, BUSINESS PHONE NO. STATE ZIP CODE COUNTY COUNTRY YEARS OF RESIDENCE ( ) ( AREA CODE, HOME PHONE NO. ) ( FAX NO. ) E-MAIL ADDRESS NUMBER AND STREET (Additional Space) NUMBER AND STREET (Previous address) CITY STATE ZIP CODE COUNTY COUNTRY HOW LONG HAVE YOU BEEN EMPLOYED BY THE ABOVE FIRM? DO YOU HAVE ANY INTEREST, DIRECTLY OR INDIRECTLY, IN ANY OTHER ALCOHOLIC BEVERAGE BUSINESS? [ ] YES [ ] NO (if "Yes", provide the following): STI NUMBER LEGAL BUSINESS NAME ALCOHOLIC LICENSE NUMBER AND STREET ADDRESS (Business) NUMBER AND STREET ADDRESS (Additional Space) CITY AREA CODE, PHONE NUMBER STATE ZIP CODE COUNTY COUNTRY ( ) HAVE YOU EVER BEEN ARRESTED, OR HELD BY FEDERAL, STATE, OR OTHER LAW-ENFORCEMENT AUTHORITIES, FOR ANY VIOLATION OF ANY FEDERAL LAW, STATE LAW, COUNTY OR MUNICIPAL LAW, REGULATION OR ORDINANCE? (Do not include traffic violations. All other charges must be included even if they are dismissed. Give reason charged or held, date, place were charged and disposition.) American LegalNet, Inc. www.FormsWorkFlow.com ATT-15 (Rev. 5/11) APPLICATION FOR ALCOHOL PERMIT OFFICE USE ONLY 21. PROVIDE EMPLOYMENT HISTORY FOR THE PAST FIVE (5) YEARS FROM Month Year EMPLOYER'S NAME AND ADDRESS POSITION OATH I DECLARE UNDER PENALTY OF PERJURY THAT THIS STATEMENT HAS BEEN EXAMINED BY ME, AND TO THE BEST OF MY KNOWLEDGE AND BELIEF IS TRUE, CORRECT, AND COMPLETE. __________________________________ Signature ______________________________ Title (Must be signed by applicant) I HEREBY CERTIFY___________________
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