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State Alcohol License Application For Wholesaler-Importer-Broker-Manufacturer-Foreign Importer And Foreign Producer ATT-6 - Georgia
| State Alcohol License Application For Wholesaler-Importer-Broker-Manufacturer-Foreign Importer And Foreign Producer Form. This is a Georgia form and can be used in Alcohol And Tobacco Division Department Of Revenue Statewide . |
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ATT-6 (Rev. 5/11) GEORGIA DEPARTMENT OF REVENUE ALCOHOL AND TOBACCO DIVISION P.O. BOX 49728 ATLANTA, GA 30359 (404) 417-4870 STATE ALCOHOL LICENSE APPLICATION WHOLESALER / MANUFACTURER / SHIPPER PRINT OR TYPE APPLICATION IDENTIFICATION SECTION 1a. Georgia Sales Tax Number 2a. 3a. State DBA OR Trade Name Business Address Zip Code+4 Phone Total Amount Received OFFICE USE ONLY $ STATE ALCOHOL LICENSE NUMBER 1. 2. 3. 4. 5. 6. 7. 9. 10. 12. 13. If Issued a Georgia State Taxpayer Identifier (STI) Number, Enter here: Legal Business Name Physical Location Address (Do not enter Post Office Box) City Email County Web Address ( ) ( Fa x ) Proprietorship Partnership Corporation LLC LP LLP License Year Application Submitted For: ALCOHOL INFORMATION SECTION 8. Name of Licensee: If Licensee is not a Proprietorship Provide Name and Address of Registered Agent: Name: Sales Tax Number Address: 11. Withholding Tax Number To which local governments will you pay ad valorem tax? Which local governments will be issuing your alcohol license(s)? Name(s) City 14. or County FEE SECTION When or will you begin selling alcohol beverages for which this application is made? IN-STATE APPLICANT TYPE OF LICENSE (Check only one major category that applies) + $100.00 Investigation Fee Beer Fee $500.00 Wine Fee $500.00 Liquor Fee $1,000.00 FARM WINERY-Fee $50.00 WHOLESALER IMPORTER OUT- OF STATE APPLICANT BROKER +100.00 Investigation Fee Beer Fee $500.00 Wine Fee $500.00 Liquor- Fee $1,000.00 +100.00 Investigation Fee Beer Fee $50.00 Wine Fee $50.00 Liquor Fee $100.00 MANUFACTURER - WINERY- WINE - Fee $1,000.00 MANUFACTURER - DISTILLERY - LIQUOR - Fee $1,000.00 MANUFACTURER - BREWERY- MALT BEVERAGE - Fee $1,000.00 BREWPUB- Fee $1,000.00 NON-BEVERAGE ALCOHOL MANUFACTURER- No Fee NON-BEVERAGE ALCOHOL IMPORTER- No Fee WINERY SPECIAL ORDER SHIPPING-Fee $50.00 } + $100.00 Investigation Fee For Each Application. NOTE: $100.00 Investigation fee is not required for Winery Special Order Shipping. DO YOU COMPLY WITH THE DISTANCE REQUIREMENTS OF O.C.G.A. 3-3-21 AND REGULATION 560-2-2-.12 BELOW? 15. Yes No N/A OUT-OF STATE APPLICANT No Person knowingly and intentionally may sell or offer to sell: A. Any liquor within 600 feet of any school ground. B. Any malt beverages or wine within 300 feet of any shcool ground. C. Any liquor within 300 feet of any church building. D. Any liquor, malt beverages and/or wine within 300 feet of any government owned and operated alcohol treatment center. American LegalNet, Inc. www.FormsWorkFlow.com ATT-6 (Rev. 5/11) 16. DO YOU COMPLY WITH THE REQUIREMENTS OF REGULATION 560-2-2.10? Yes No Neither a manufacturer, producer, shipper, importer, or broker, whether licensed in this State, or not, nor any of his employees or members of such manufacturer's, producer's shipper's, importer's or broker's immediate family shall have, own or enjoy any ownership interest in , or partnership arrangement or other business association with the business of any wholesaler, retail dealer or retail consumption dealer licensee. Neither a wholesaler, whether licensed in this State or not, nor any of his employees, or any members of such wholesaler's family shall have, own or enjoy any ownership interest in, or partnership arrangement or other business association with the business of any manufacturer, producer, shipper, importer, broker, retail dealer or retail consumption dealer; provided nothing herein shall prohibit such persons from owning stock in such firms when such firms' stock is publicly traded on a national exchange or over the counter. Neither a retail dealer or retail consumption dealer, whether licensed in this State or not, nor any of his employees or members of such retail dealer's or retail consumption dealer's immediate family shall have, own or enjoy ownership interest in, or partnership arrangement or other business association with the business of any wholesaler, manufacturer, producer, shipper, importer or broker. SIGNATURE SECTION I DECLARE, UNDER PENALTY OF PERJURY, THAT THIS APPLICATION HAS BEEN EXAMINED BY ME, AND TO THE BEST OF MY KNOWLEDGE AND BELIEF IS TRUE, CORRECT, AND COMPLETE. ____________________________________ Signature ____________________________________ Title _____________________ Date (Must be signed by licensee. If the licensee is a corporation, must be signed by an officer of the corporation. Stamped signature is not acceptable) Incomplete applications will not be processed. All required documents must accompany the application. American LegalNet, Inc. www.FormsWorkFlow.com Affidavit of Compliance with O.C.G.A. 50-36-1 "Verification of Lawful Presence within the United States" O.C.G.A. 50-36-1 requires that applicants applying for such things as licenses for public benefits complete a signed and sworn affidavit verifying the applicant's lawful presence in the United States. Therefore, the applicant must answer the following questions: The applicant is a United States citizen or legal permanent resident at least eighteen (18) years old. Yes ______ No ______ The applicant is a qualified alien or nonimmigrant under the federal Immigration and Nationality Act, Title 8 U.S.C., as amended, at least eighteen (18) years old, and is lawfully present in the United States. The applicant's alien number issued by the Department of Homeland Security or other federal immigration agency must be provided. Yes ______ No ______ Alien Number ____________________________________ O.C.G.A 50-36-1 states that "Any person who knowingly and willfully makes a false, fictitious, or fraudulent statement of representation in an affidavit executed pursuant to this Code section shall be guilty of a violation of Code Section 16-10-20." I declare, under penalty of law, that this affidavit has been completed by me and is true and correct. ___________________________________________________________________________________________ Signature Title Date (Must be signed by applicant. If the applicant is a corporation, must be signed by an officer of the corporation. STAMPED SIGNATURE IS NOT ACCEPTABLE) I hereby certify that__________________________________________________________ is personally known, or verified by me, that the applicant signed this application after stating to me his or her personal knowledge and understanding of all statements and, under oath actually administered by me, has sworn that the statements and answers contained in this affidavit are true. This _________ day of _______
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