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Vendor Representative Permit Application - North Carolina
| Vendor Representative Permit Application Form. This is a North Carolina form and can be used in Alcoholic Beverage Control Commission Statewide . |
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NORTH CAROLINA ALCOHOLIC BEVERAGE CONTROL COMMISSION VENDOR REPRESENTATIVE PERMIT APPLICATION Application # Temporary # Date Issued Exp. Date Fee Paid: Date Rec'd: Rec'd By: Approved .. . . . . . . . . . . . . Rejected .. . . . . . . . . . . . . By Date A certified check, cashier's check, money order, or company check, in the amount of $50.00 must be submitted with this application. North Carolina Vendors only. County in which vendors business is located. Vendor Name Company (winery, brewery, importer or nonresident vendor) that you represent. Location Address of Vendor Street/Route City City State State Zip Code Zip Code Mailing Address of Vendor Street/Route/PO Box Applicant's Complete Name First (no abbreviations) Middle City State Last Zip Code Applicant's Resident Address Street/Route Business Address, if different than above Street/Route City State Zip Code Date of Birth Home Telephone # ( ) Email Address Business Telephone # ( ) Do you hold any financial interest in, or do you receive, any profits or salary from any retail malt beverage or wine outlet in North Carolina? Yes No If yes, explain on reverse side. I certify under oath or affirmation that I am not less than 21 years of age, that I have not been convicted of a felony within the past three years, and if convicted of a felony before then, I have had my citizenship restored; that I have not been convicted of an alcoholic beverage or misdemeanor controlled substance offense within the past two years, and that I have not had any alcoholic beverage permit revoked within the past three years. Signature of Applicant Date Sworn to and subscribed before me this the Day Month Year My commission expires: Date of expiration Notary or other person qualified by law to administer oaths MAIL COMPLETED APPLICATION TO: If sending by U.S. Postal Service (regular mail): Is sending by U.S. Postal Service EXPRESS MAIL or by FEDEX or UPS: NC ABC COMMISSION ATTN: PRODUCT COMPLIANCE 4307 MAIL SERVICE CENTER RALEIGH NC 27610 NC ABC COMMISSION ATTN: PRODUCT COMPLIANCE 3322 GARNER ROAD RALEIGH NC 27610 Vendor RepresentativeApplication Rev 4/2006 American LegalNet, Inc. www.FormsWorkFlow.com NORTH CAROLINA ALCOHOLIC BEVERAGE CONTROL COMMISSION INVESTIGATIVE REPORT TO BE COMPLETED BY ALCOHOL LAW ENFORCEMENT AGENT ONLY. Is individual filing application at least 21 years of age? Has individual ever had an ABC permit Yes Suspended ? No Revoked ? Yes No Has the individual ever been a member or a manager of a N.C. corporation that held ABC permits? Corporation Name: Has this individual held ABC permits in N.C. before? Is individual a bona fide resident of North Carolina? History of applicant's past operation and/or reputation (explain) Yes Yes File #: No No Are there pending violations against this individual? Yes No If yes, explain Have you reviewed the application with the applicant to determine that it is complete and correct? Criminal record Court record attached Yes No Yes No Are there any reasons permits should not be issued to this applicant? If yes explain: Agent's Signature Date Vendor RepresentativeApplication Rev 4/2006 American LegalNet, Inc. www.FormsWorkFlow.com
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